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    Proforma Ophthalmic History

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    mahir patel
    Taking a thorough patient history is essential for eye care, as it helps focus the examination and diagnosis, understand the impact on the patient, and identify barriers to treatment. A structured approach should explore the chief complaint, present and past ocular and medical history, family history, medications, allergies and social context to provide holistic care and build trust.

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    Proforma Ophthalmic History

    Uploaded by

    mahir patel
    37 views3 pages
    Taking a thorough patient history is essential for eye care, as it helps focus the examination and diagnosis, understand the impact on the patient, and identify barriers to treatment. A structured approach should explore the chief complaint, present and past ocular and medical history, family history, medications, allergies and social context to provide holistic care and build trust.

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    Proforma Ophthalmic History

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    Taking a thorough patient history is essential for eye care, as it helps focus the examination and diagnosis, understand the impact on the patient, and identify barriers to treatment. A structured approach should explore the chief complaint, present and past ocular and medical history, family history, medications, allergies and social context to provide holistic care and build trust.

    Copyright:

    © All Rights Reserved
    Download as TXT, PDF, TXT or read online from Scribd
    Download as txt, pdf, or txt
    37 views3 pages

    Proforma Ophthalmic History

    Uploaded by

    mahir patel
    Taking a thorough patient history is essential for eye care, as it helps focus the examination and diagnosis, understand the impact on the patient, and identify barriers to treatment. A structured approach should explore the chief complaint, present and past ocular and medical history, family history, medications, allergies and social context to provide holistic care and build trust.

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    © All Rights Reserved
    Download as TXT, PDF, TXT or read online from Scribd
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    of 3

    Taking a good history not only helps you to make a diagnosis, it can also help you

    to understand the impact of the condition on the patient and identify any obstacles
    to treatment.

    It is impossible to over-emphasise the importance of taking a careful history when


    assessing an eye patient. Taking a good history can help to focus your examination
    and indicate what investigations are needed. It can also help you to understand the
    impact of the condition on the patient and pinpoint any difficulties they may have
    adhering to treatment.

    This is also your opportunity to focus on the patient as a person and to form a
    relationship of trust, respect and mutual understanding.

    How to structure history taking


    To ensure you don't miss anything important, structure your history taking
    carefully. Ask about:

    Tip: You can use this bulleted list as a checklist Copy and keep it where you can
    see it during history taking to help you to stay on track and ensure that you will
    not miss anything important.

    Each of these is discussed in more detail below.

    Top tips for taking a good history


    Introduce yourself to the patient – this creates a friendly environment.

    Respect the patient's privacy and confidentiality while taking the history

    Ask questions that are direct, simple and clear. Avoid using medical terms and
    explain things in ordinary language as much as possible.

    Be a good listener. Avoid interrupting or rushing the patient. Show them that you
    are listening and paying attention: make eye contact as appropriate and ask if you
    are not sure about something they said. It is often useful to use open questions
    (e.g., how are you?) and closed questions (e.g., yes/no answers) to help focus the
    discussion.

    Try to see things from the patient's point of view and make an effort to understand
    them and their circumstances, especially when these are very different from your
    own.

    Be aware that patients who are older, or who have disabilities (including hearing
    impairment, speech difficulties or a learning disability) may need a bit more time
    or may struggle to express themselves. This may cause them some anxiety, so remain
    patient and reassure them that you are there to listen.

    Personal and demographic data


    Ask the patient's personal details:

    Name, for identification, filing and patient follow-up

    Address and mobile phone number, for follow-up and to identify patients from areas
    with endemic diseases

    Age and gender, for noting down and ruling out any diseases associated with
    different age groups and/or sex

    Language
    Disability

    Patient's occupation, daily tasks and hobbies.

    Recording the age, gender, language and disability status of patients allows you to
    monitor who is, and is not, coming to your eye clinic or hospital. Compare these
    figures with the population to identify groups that are under-represented, e.g.,
    girls with other disabilities, and plan ways to reach out to them.

    Understanding a patient's occupation, daily tasks (e.g., looking after


    grandchildren) and hobbies is helpful for finding out a patient's visual needs and
    understanding any eye manifestations or symptoms as a result of occupational
    hazards.

    Reason for visit/Presenting complaint


    Ask the main reason why the patient has come to seek an eye examination.

    Record the main presenting symptoms in the patient's own words and in a
    chronological order. The four main groups of symptoms are:

    Red, sore, painful eye or eyes (including injury to the eye)

    Decreased distance vision in one or both eyes, whether suddenly or gradually

    A reduced ability to read small print or see near objects after the age of 40 years

    Any other specific eye symptom, such as double vision, swelling of an eyelid,
    watering or squint.

    History of presenting complaint


    This is an elaboration of the presenting complaint and provides more detail. The
    patient should be encouraged to explain their complaint in detail and the person
    taking history should be a patient listener. While taking a history of the
    presenting complaint, it is important to have potential diagnoses in mind. For each
    complaint, ask about:

    Onset (sudden or gradual)

    Course (how it has progressed)

    Duration (how long)

    Severity

    Location (involving one or both eyes)

    Any relevant associated symptoms

    Any similar problems in the past

    Previous medical advice and any current medication.

    Past eye history


    Ask for detail about any previous eye problems

    History of similar eye complaints in the past. This is important in recurrent


    conditions such as herpes simplex keratitis, allergic conjunctivitis, uveitis and
    recurrent corneal erosions
    History of similar complaints in the other eye is important in bilateral conditions
    such as uveitis, cataract

    History of past trauma to the eye may explain occurrence of conditions such as
    cataract and retinal detachment

    History of eye surgery. It is important to ask about any ocular surgery in the past
    such as cataract extraction, muscle surgery, glaucoma, or retinal surgery

    Other symptoms. Ask whether the patient has any other specific eye symptoms.

    General medical history


    Ask about any current and past medical conditions. These include conditions such as
    diabetes, hypertension, arthiritis, HIV, asthma and eczema.

    Family eye history


    It is important to ask the patient whether any other member of the family has a
    similar condition or another eye disease. This can help to establish familial
    predisposition of inheritable ocular disorders like glaucoma, retinoblastoma or
    congenital eye diseases, diabetes and hypertension.

    Medication history
    Ask about present and past medications for both ocular and medical conditions.
    Don't overlook any medications that the patient may have stopped taking some time
    ago. Some medications are important in the etiology of ocular conditions.

    It is also helpful to ask whether the patient has been able to use the medication
    as prescribed (their compliance). If a medication is ineffective, you want to know
    whether the patient is actually using the medication as prescribed, for example
    glaucoma medications.

    Using your own discretion, it is helpful to find out whether access to medication
    prescribed is a problem. This helps to ascertain whether cost or other concerns are
    a potential reason for non-compliance. There could also be practical issues, such
    as difficulty instilling eyedrops or forgetting to do so.

    Do not forget to ask in a non-judgmental way about traditional/herbal medication


    use.

    Allergies
    Ask about any allergies to medications or other substances.

    Social history
    Birth and immunisation history
    For children, the birth history (prematurity) and immunisation status can be
    important.

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