A complete case history taking
should be structured as;
- Demographic Data.
- Chief Complaints.
- Ocular History.
- Health history and Medication.
- Family Eye History.
- Family Medical History.
Demographic Data
Demographic data comprises of the
following;
Chief Complaints
While taking the case history,
the optometrist should ask the patient what brought him/her to the clinic or
what problem he/she is having with his/her vision.
Both the chief and secondary
complaints should be recorded in the patient’s own words to prevent
misinterpretation and it should be detailed by stating it’s severity,
progression, mode of onset with duration and accompaniment of each symptom.
Ocular/Visual History
The optometrist should ask the
patient the following questions;
- When was your last eye examination?
- How long have you been wearing glasses? (If he/she is wearing spectacles).
- Have ever had any eye diseases such as injuries (trauma) of surgery?
Health History and Medication
The optometrist should ask the
patient the following questions;
- Are you in good health?
- Do you have any disease?
- Do you have any disease such as hypertension, diabetes etc?
- Are you on medication?
- Are you allergic to any medication?
Family Eye History
Ask the patient if anyone in
his/her family have had any eye diseases such as cataract, glaucoma,
strabismus, amblyopia, myopia, etc.
Family Medical History
Ask the patient if is there is anyone in his/her family that is suffering
from any systemic diseases such as high blood pressure, diabetes, tuberculosis,
etc.
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