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Case History Script
PURPOSE To gather information about the patient’s chief complaint，visual function，ocular and systemic health，and lifestyle．To establish a caring relationship with the patient．To begin the process of differential diagnosis and the process of patient education．
Case History Components
·Interview
1．Chief complaint．
a．Initiation：“Why did you come in today?” or “Are you having any problems with your eyes?”．
b．Elaboration of the chief complaint(FOLDARQ)．
For each complaint，the clinician asks about：
Frequency：How often does this occur?
0nset：When did the problem begin?
Location：Where is the problem located?
Duration：How long do your symptoms last?
Associated factors：What other symptoms do you experience with this problem?
Relief：What seems to make your symptoms go away?
Quality：How would you rate the severity of your symptoms?
2．Patient’s visual demands．
“What kind of work do you do?”
“What are your hobbies?”
“Do you drive?”
3．Visual efficiency, if not already covered in the chief complaint．
“Can you see clearly and comfortably both far away and close ?”
·Questionnaire
1．Patient’s eye history．
a．“When was your last eye exam? By whom? What was the outcome of that examination?”
b．Corrective lenses history．
If the patient wears glasses, ask：“How long have you been wearing glasses? Are they for distance，near，or both? Can you see clearly and comfortably with them? When were your glasses last changed?” If the patient does not currently wear glasses，ask “Have you ever worn glasses? What were they for? When did you wear them? When and why did you stop wearing them?”
“Do you wear contact lenses?”(for further contact lens history, see Chapter 6)．
2．Patient’s medical history．
“Have you ever had any medical attention to your eyes? Any surgery，injuries，or serious infections?”
“Have you ever worn an eye patch?”
“Have you ever used any medication for your eyes?”
“Have yon ever been told that you have an eye turn or a lazy eye?”
“Have you ever been told that you have cataracts，glaucoma, or any other eye disease?”
“How is your general health?”
“When was your last physical examination? By whom?”
“Are you currently under the care of a physician for any health condition?”
“Have you ever been told that you have diabetes，high blood pressure，thyroid disease，heart disease，or any infectious disease?”
“Are you taking any medications? If yes, what medication, how long have you been taking the medication, what is it for, and what is the dosage?”
“Do you have any allergies? If yes，to what，what are your symptoms, and how are your allergies treated?”
3．Symptoms of common eye problems．
“Have you experienced any of the following：flashes of light floaters，halos around lights，double vision, frequent or severe headaches，eye pain，redness，tearing，or a sandy，gritty feeling in your eyes?”
4．Family history．
“Has anyone in your family had cataracts, glaucoma, or blindness? If yes, who，when，for how long，and what was the treatment?”
“Has anyone in your family had diabetes, high blood pressure, thyroid disease，heart disease，or any infectious disease? If yes，who，when，for how long，and what was the treatment?”
·Summary
“Is there anything else about your eyes，your general health，or your family’s eyes or health that you would like to tell me about?”
“The reason for your visit today is．．．and you have concerns about．．．?”
RECORDING
·Record all information including the negatives. |
