Steps in Optometry Case History Taking

A complete case history taking should be structured as;

1. Demographic Data.
2. Chief Complaints.
3. Ocular History.
4. Health history and Medication.
5. Family Eye History.
6. Family Medical History.

Demographic Data

Demographic data comprises of the following;

Name, address, phone number, age, gender, occupation, religion, marital status, hobbies etc.

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.