HISTORY AND PHYSICAL FORM

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: