San jacinto eye care technology center wrkup sheet 17
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San jacinto eye care technology center wrkup sheet 17
- 1. San Jacinto College Eye Care Technology Patient:_____________________________________Age/Race:_________________ Date:____________ Mental Orientation: T T P nl x ____ CC: ____________________________________________________________ _________________________________________________________________ Medications: _____________________________________________ ________________________________________________________________ _________________________________________________________ ________________________________________________________________ ________________________________________________________ ________________________________________________________________ ________________________________________________________ HPI: ____________________________________________________________ __________________________________________________________ ____________________________________________________________ ________________________________________________________ _________________________________________________________________ POH: __________________________________________________________ Allergies:__________________________________________________ ______________________________________________________________ ___________________________________________________________ _____________________________________________________________ ___________________________________________________________ _____________________________________________________________ ___________________________________________________________ Medical Hx: ____________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ Surgeries: ________________________________________________________ _________________________________________________________ Social Hx: __________________________________________________ Family Hx: ______________________________________________________ ___________________________________________________________ __________________________________________________ __________________________________________________________ ____________________________________________________________ ___________________________________________________________ D Va ________________ D Va ______________ ph____________ _________________________________ _________________________________ _________________ ________________ ph_____________ Add: ____________________ N Va: ____________ / ____________ ____________________________= 20 / _______ ____________________________= 20 / _______ add ______________ Dilation: _______________ Time: ________________ Tech initials: __________ ______________________________________________________________________________________________________________________________________ SLE: OD OS Fundus: Lids/Lashes: ____________________________ C/D: _______ C/D:_______ Conjunctiva: ____________________________ Cornea: ____________________________ A/C: ____________________________ Iris: ____________________________ IMPRESSION: Lens: ____________________________ RTC: B. Milstein, MD W Contact Lens Hx: Pupil Evaluation PERRLA _____ S S R N _____ _____ ______ _____ _____ _____ ______ _____ APD ____ EOM Full Restricted Ancillary Testing T____ / @ CVF: Full AR MR