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Symptoms: • Location: OD OS OU_________________________________________. • Quality: Blur Pain Tear Dry Itch Red. • Severity: Mild Mod Severe - Pain ___/10.
Typology: Summaries
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CC : ___________________________________________________________________________________ Dr. O’Daniel
Pupils PERRL
V.F. Confrontations / FDT Full OU defect OD / OS / OU
Tatum Dr O Exam 01-19-
Symptoms :_________________________________________________ Location : OD OS OU_________________________________________ Quality : Blur Pain Tear Dry Itch Red ____________________________ Severity : Mild Mod Severe - Pain ___/ Duration : _____ Day Week Month Year Timing : Acute Constant Intermittent ___________________________ Context: Far Near Computer __________________________________ Modifiers : Drops / Glasses help __________________________________ Head/Face Normal Mood/Affect (anxiety/agitation/depression) Normal Oriented (person/time/place) Yes No
HabRx OD 20/ Add+ C.T. Dist. O rtho Near NPC
OS 20/ bi / tri / pal Versions Smooth & Full OU restricted
K’s OD / @ S / D Phorias
Near
Lateral
Dist.
Vertical
OS / @ S / D Auto OD Near OS NRA VA’S 20/ #7 OD^^20 /^ Ph^ PRA^20 / OS 20 / Ph Ranges Lids/Lashes clear OU Vitreous clear OU Conj. clear OU Macula clear OU Corneas clear OU Vessels clear OU Lens clear OU ONH clear OU Iris clear OU Periphery clear OU A.C. clear OU Angle. OD: 0 1 2 3 4 OS: 0 1 2 3 4 C/D OD ______ OS ______
OD ______ NCT Icare Goldman Tonometry OS ______ @ _______am / pm
Dilated OD OS OU Time: _____ am / pm Procaine T 1/2% 1% PE 2.5% Paremyd
Dermato____ NS____ AC____ PCO ____ Dermato____ NS____ AC____ PCO ____ Floaters____ PVD____ Floaters____ PVD____
Direct 78D 90 D SF 20D Photo
Pterygium___ Bleph___________ Bleph__________ Pterygium___ Arcus__ Arcus__ Ping__ Ping__
Cells___ Cells___ ___ RPE Change___
Conj Inj ____ NaFl SPK ____ TBUT ___ Conj Inj ____ NaFl SPK ____ TBUT ___ Dry ARMD _____ Drusen____ Dry ARMD _____ Drusen____
IMPRESSION
Ocular Health Clear and Quiet OU
PLAN RTO : _____ day week month - 1 year default
Myopia H52.1__ Astig H52.22__ Hyper H52.0__ Pres H52. NS H25.1__ DES H16.223 ARMD H35.3131 DM2 E11.
Contact lens fitting – see CL fitting sheet
Add
+.25 PAL/Tri
Mr.___ Mrs.___ Ms.___ Dr.___ Date ____/____/______
Last Name _______________________________ First ___________________________ Patient New / Previous
Address ______________________________________ City _______________________ Birth Date ____/____/______
State ______________ Zip ______________ Email ______________________________ Occupation __________________
Phone : Home _________________ Work _________________ Cell _________________ Last Eye Exam mo____/yr______
Vision Insurance _________________ ID# ________________ Medical Insurance ________________ ID# ________________
Primary Member’s Name __________________________ Primary’s Last 4 SSN _______ Primary’s Birth Date ____/____/____
Referred by: Family Friend Co-worker Insurance Drove by Internet Site ________________________
Do you have any allergies to medications? no yes If yes, explain: ___________________________________
List any medications you take (including oral contraceptives, aspirin, over the counter medications and home remedies):
IF YOU ARE A PREVIOUS PATIENT AND THERE ARE NO CHANGES IN YOUR OCULAR/MEDICAL OR FAMILY HISTORY YOU MAY CHECK THE APPROPRIATE BOX AND SKIP THAT SECTION. No change in Ocular Medical History No change in Family History
Last Medical Exam ____/____/______ Medical Dr’s Name _____________________
List any of the following that you have had: crossed eyes, lazy eye, drooping eyelid, prominent eyes, glaucoma, retinal disease, cataracts, eye infections or eye injury: ________________________________________________________________________ Are you pregnant and/or nursing? no yes Do you wear glasses? no yes If yes, how old is your present pair of glasses? _____________
Are they comfortable? no yes How often do you replace them? ________________________
Please check any conditions that you have or have had in the past: Loss of Vision Dryness Burning Chronic Infection of Eye/Lid Blurred Vision Mucous Discharge Foreign Body Sensation Styes or Chalazions Distorted Vision/Halos Redness Excess Tearing/Watering Flashes/Floaters in Vision Loss of Side Vision Sandy or Gritty Feeling Glare/Light Sensitivity Tired Eyes Double Vision Itching Eye Pain or Soreness Other__________________
Please check any conditions that apply to your immediate family members:
Blindness Macular Degeneration Cancer Kidney Disease Cataract Retinal Detachment Diabetes Lupus Crossed Eyes Retinal Disease Heart Disease Thyroid Disease Glaucoma Arthritis High Blood Pressure Other__________________
Acknowledgement of Receipt of Privacy Notice
The Health Insurance Portability and Accountability Act (HIPAA) is a federal law designated to protect the privacy of your health information. We understand that the information about you and your health is personal and our doctors and staff are committed to protecting the privacy of that information. Because of this commitment, we must obtain your special authorization before we may use or disclose your protected health information to any party. This office will only use and disclose necessary personal health information to permit the office to perform its administrative duties, provide eye care services, process vision benefit claims, or mail exam recalls. By signing below, I acknowledge that I have read/received the copy of the Notice of Privacy Practices for review.