This document contains a patient's eye exam record including their chief complaint, medical history, medications, allergies and social history. It documents measurements of their vision, dilation of their pupils, examination of their lids, lashes, conjunctiva, cornea, anterior chamber, iris, lens and fundus. Impression and recommendation for follow up with their doctor are also included.

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