LOW VISION PATIENT'S HISTORY TAKING

1. LOW VISION PATIENT’S HISTORY TAKING
1.GENERAL INFORMATION: -
 NAME- ………………………………………………………………………………….
 AGE- ……………………………………………………………………… DATE- ………………………………………..
 GENDER- ………………………………………………………………
 ADDRESS-
………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
 EDUCATION-- …………………………………………………………………………………………………………..
 EDUCATION GRADE-- …………………………………………………………………………………………
 OCCUPATION- ………………………………………………………………………………………….
 FAMILY INCOME-- ………………………………………………………………………
2.SYSTEMIC HISTORY---
DISEASE --- (IFANY)
MEDICATION--
DURATION--
3.OCULAR HISTORY---
DISEASE--- (IFANY)
MEDICATION--
DURATION—
PGP--
4.FAMILY HISTORY-
DISEASE--- (IFANY)
MEDICATION-
ONSET-
5.LOW VISION HISTORY--
OPTICAL DEVICE-
NON-OPTICALDEVICE-
ELECTRICAL DEVICE –

2. WHAT SHOULD BE AVOIDE—
6.VISUAL ACTIVITY: -
ABLE TO DO / NOT ABLE TO DO / DIFFICULTY TO DO
COOKING--
READING--
WALKING --
MOBILE USING --
OCULAR EXAMINATION:-
1. SLIT LAMP EXAMINATION:--
a. Cornea-
b. Sclera-
c. Conjunctiva-
d. Pupil-
e. Iris-
f. Lens-
2. VISUAL ACUITY: - (LOGMARCHART)
OD OS
Near-
Distance-
3. REFRACTION: -
Retinoscopy-
Subjective refraction-
Objective refraction-
4. CONTRAST SENSITIVITY--
Pelli robsonchart-
5. COLOR VISION TEST: - D15

3. 6.RAPD TEST--
7.GLARE TEST-
8. POSTERIOR SEGMENT EXAMINATION--
Retina examination-
OCT-
FFA-
9. ADVICE/ PRESCRIBED---
DEVICE USE --- OPTICAL DEVICE/ NON-OPTICALDEVICE/ ELECTRICAL DEVICE
WHAT TO DO—
NOT TO DO—
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INDRAJIT BISWAS {3RD
YR}