Risk Management
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History and Physical Form
HISTORY AND PHYSICAL FORM (Courtesy of Daniel A. Long, MD, a practicing ophthalmologist in Gretna, LA.)
Patient Name: Date: Age:
Chief Complaint: Allergy:
Meds: Beta Bl__________ 1/4 1/2 Pilo 1 2 4 Prop N25 50 D250 500
Illness: HBP IDDM NIDDM ASCVD MI CHF Asthma COPD Poor circ Thyroid
Eye History: Cataract Glaucoma CL Surgery Amblyopia
FH: Cataract Glaucoma AMD Strabismus Amblyopia
VA: sc OD 20/20 25 30 40 50 60 70 80 100 200 400 FC HM LP
OS 20/20 25 30 40 50 60 70 80 100 200 400 FC HM LP
cc OD 20/20 25 30 40 50 60 70 80 100 200 400 FC HM LP
OS 20/20 25 30 40 50 60 70 80 100 200 400 FC HM LP
REFR: OD 20/ Add: J
OS 20/ Add: J
CYCLO: OD 20/
OS 20/
STEREO: Fly Animals 1 2 3 Dots 1 2 3 4 5 6 7 8 9
COLOR: Normal Abn
EXT. OD Clear Hyperemia 1 2 3 Edema 1 2 3 Ptosis 1 2 3 mm
OS Clear Hyperemia 1 2 3 Edema 1 2 3 Ptosis 1 2 3 mm
PUPILS: OD 1 2 3 4 5 6 1+ 2+ 3+ Aff defect – 1 2 3
OS 1 2 3 4 5 6 1+ 2+ 3+ Aff defect – 1 2 3
EOM: OD Full MB:sc Ortho EP ET XP XT HP HT OD OS PD
cc Ortho EP ET XP XT HP HT OD OS PD
SLE: OD LIDS Clear Bleph Ant Post Mix 1 2 3 Pap 1 2 3 Foll 1 2 3
CORNEA Clear SPK 1 2 3 Abrasion
AC Clear C 1 2 3 F1 1 2 3 Hyph IRIS Clear PI open
LENS Clear NS 1 2 3 4 Cort 1 2 3 4 PSC 1 2 3 4 Aphakia
PC Clear 1 2 3 4
OS LIDS Clear Bleph Ant Post Mix 1 2 3 Pap 1 2 3 Foll 1 2 3
CORNEA Clear SPK 1 2 3 Abrasion
AC Clear C 1 2 3 F1 1 2 3 Hyph IRIS Clear PI open
LENS Clear NS 1 2 3 4 Cort 1 2 3 4 PSC 1 2 3 4 Aphakia
PC Clear 1 2 3 4
GONIO: OD 0 10 20 30 40 Pigm 1 2 3 4 PAS – +
OS 0 10 20 30 40 Pigm 1 2 3 4 PAS – +
OPHTH: OD Clear C/D 0 .1 .2 .3 .4 .5 .6 .7 .8 .9 Symm Pale
Cup Shallow Med Deep
Macula NL Flat Pigm Ch 1 2 3 Drus 1 2 3 Hem Edema
MA Hem Hard ex CW NVD NVE Periph NL
OS Clear C/D 0 .1 .2 .3 .4 .5 .6 .7 .8 .9 Symm Pale
Cup Shallow Med Deep
Macula NL Flat Pigm Ch 1 2 3 Drus 1 2 3 Hem Edema
MA Hem Hard ex CW NVD NVE Periph NL
IOP: OD 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Time
OS 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 Time
IMPRESSION:
PLAN:
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