Diagnosis
4
History
In general, a thorough history may include the following items:
• Demographic data (e.g., name, date of birth, gender, and ethnicity or race)
• Patient's other pertinent health care providers
• Chief complaint and history of present illness
• Present status of visual function (e.g., patient's self-assessment of visual status, visual
needs, any recent or current visual symptoms, and use of eyeglasses or contact lenses)
• Ocular symptoms (e.g., eyelid swelling, diplopia, redness, photophobia)
• Past ocular history (e.g., prior eye diseases, injuries, surgery, including cosmetic eyelid
and refractive surgery, or other treatments and medications)
• Systemic history: medical conditions and previous surgery
• Medications: ophthalmic and systemic medications currently used, including
nutritional supplements and other over-the-counter products
• Allergies or adverse reactions to medications
• Family history: pertinent familial ocular (e.g., glaucoma, age-related macular
degeneration) and systemic disease
• Social history (e.g., occupation; tobacco, alcohol, illicit drug use; family and living
situation as appropriate)
• Directed review of systems
Care Process
