1. OPTO 4101: Refraction1- lab L01: History taking
Mohammed A.M Aljarousha
Department of Optometry
Faculty of Allied Health Sciences
Islamic University-Gaza

2. Components of the history
The components of the history are:
Chief complaint
Present illness
Past ocular history
Ocular medications
General medical & surgical history
Systemic medications
Family history

3. Chief complaint
Questions for eliciting the chief ophthalmologic complaint
What are the main problems that you are having with your eyes?
What other problems are you having with your eyes?
Why did you come here?
What is the main problem that you would like me to address?

4. Present illness Present illness can be classified into:
Disturbances of vision
Ocular Pain or discomfort
Abnormal ocular secretions
Abnormal appearances

5. Disturbances of vision
Blurred or decreased central vision (distance or near or both)

6. Disturbances of vision
Decreased peripheral vision

7. Disturbances of vision
Micropsia

8. Disturbances of vision
Photophobia

9. Disturbances of vision
Diplopia

10. Disturbances of vision
Dyslexia

11. Color vision abnormalities

12. Ocular pain or discomfort
Foreign body sensation

13. Ocular pain or discomfort
Headache

14. Ocular pain or discomfort
Burning

15. Ocular pain or discomfort
Dryness

16. Ocular pain or discomfort
Itching

17. Ocular pain or discomfort
Asthenopia

18. Abnormal ocular secretions
Lacrimation

19. Abnormal ocular secretion
Epiphora

20. Abnormal ocular secretion
Discharge

21. Abnormal appearances
Ptosis

22. Abnormal appearances
Exophthalmos

23. Abnormal appearances
Squint

24. Past ocular history Use of eyeglasses or contact lenses
Use of ocular medications in the past.
Ocular surgery (including laser surgery)
Ocular trauma
Amblyopia (lazy eye)

25. Ocular medications miotic drugs such as pilocarpine
Dilating Cycloplegia or mydriatic drugs such as atropine, homatropine, cyclopentolate, phenylephrine
Many medications including certain antibiotic, artificial tears, corticosteroids.

26. General medical and surgical history
Diabetes mellitus (DM)
Hypertension
Rheumatoid arthritis

27. Systemic medications Antibiotics Sleeping pills
Anti-inflammatory agents
Oral contraceptives
Vitamins

28. Family history * Ocular There are two in number
Here/His parents wearing glasses or contact lenses
Corneal diseases
Glaucoma
Cataract
Retinal diseases
Refractive surgery (including laser surgery)
* Non-ocular
Thyroid disease DM
Various hereditary syndrome
Hypertension