chief complaint - Marshall Eye Care

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chief complaint - Marshall Eye Care
CHIEF COMPLAINT: ___________________________________________________________________________________
__________________________________________________________________________________________________
HISTORY
PSYCH: MOOD (ANXIETY/DEPRESSION) NORMAL
NEURO: PERSON/PLACE/TIME YES NO
HPI:
MEDICAL HX& ROS FROM _____/____/_____
NO CHANGES
UPDATED
SYMPTOMS ______________________________________
DRUG ALLERGIES LISTED
NKDA
REVIEWED DR INTIALS ______
LOCATION _______________________________________
QUALITY _______________________________________
CURRENT SPECTACLES
SEVERITY ________________________________________
OD _______________________________ ADD _________
DURATION ______________________________________
OS ________________________________ ADD _________
TIMING _________________________________________
CONTEXT ________________________________________
CONTACT LENS BRAND:
SOLUTION:
MODIFIERS ______________________________________
OD ___________________________
OS ___________________________
REPLACEMENT:
PRE-TEST
AUTOREFRACTION OD ____________________________
K READING OD ________________________ NCT OD _____ TIME:
OS ____________________________
OS ________________________
OS ______
ENTRANCE TEST
FAR
VISUAL ACUITY
OD 20/____
AIDED / UNAIDED OS 20/____
OU 20/ ____
RETINOSCOPY
OD
OS
NEAR
PH
20/____ 20/____
20/____ 20/____
20/____ 20/____
20/
20/
REFRACTION
DISTANCE
OD
OS
20/
20/
OU 20/
OU 20/
CONFRONTATIONS FTFC OU
ABNORMAL:
AMSLER GRID
NORMAL OU
ABNORMAL:
COVERTEST FAR_______ NEAR ________
COLORVISION OD NORMAL
ABNORMAL
OS NORMAL
ABNORMAL
MOTILITY FROM NO PAIN NO DIPLOPIA ABNORMAL:
PUPILS
PERRLA NO RAPD/APD
ABNORMAL:
NPC NORMAL BREAK _____________
MADDOX ROD ____________________
NEAR @_________________
OD
20/
OS
20/
BIOMICROSCOPY
EST ANGLE OD 1 2 3 4
OS 1 2 3 4
INTERNAL
DO 90 78 66
BIO 20 30 INDENT
OD WNL
OS WNL
TEARS
LIDS/LASH
CORNEA
PAL CONJ
BULB CONJ
ANT CHMB
IRIS
LENS
DPA SE EXPLAINED
TROP .5% 1% PROP .5%
PHEN 2.5%
TETRA .5%
FLURESS
GLOSTRIP
OD WNL
OS WNL
C/D
MARGINS
MACULA
VESSELS
MEDIA
VITREOUS
PERIPH RET
GOLDMAN TONO OD ___ OS ____
ASSESSMENT:___________________________________________
PLAN: _________________________________________________
Dr.____________________
ORDER: PHOTOS OCT ONH
BINOCULAR TEST
PHORIA: FAR_____ NEAR _____ AC/A ___
VERT ______ NRA ____ PRA ____
OCT MAC PACH
VF_____ OTHER:
SPECS
OD
OS
CLS
OD
OS
BRAND:
SPH
CYL
AXIS
PRISM
ADD
BC
SPH
CYL
AXIS
ADD

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