1. Walter Huang, OD Yuanpei University Department of Optometry
Case History
Walter Huang, OD
Yuanpei University
Department of Optometry

2. Case History
The goal of case history is to obtain an understanding of the patient’s problems and needs
It consists of a series of questions to learn about the patient, the purpose for the visit, and the patient’s ocular health history and general health history

3. Case History
Case history is the most important part of the exam because it guides the exam by helping to narrow down the list of tests that the clinician must do for the remainder of the exam
It offers a good opportunity for the clinician to get to know the patient as a person and build trust with the patient

4. Chief Complaint The chief complaint is often the first question asked
It is the most important part of the case history because the clinician is trying to determine the purpose for the patient’s visit
It should be an open-ended question
Why did you come in today?
Are you having problems with your eyes?

5. Chief Complaint Frequency Onset Location How often does this occur?
Constant or intermittent?
Onset
When did the problem begin?
Recent or long-standing?
Location
Where is the problem located?
Right eye, left eye, or both eyes?
Unilateral or alternating?

6. Chief Complaint Duration Association Relief Quality
How long does it last?
Association
What other symptoms do you experience with this problem?
Relief
What seems to make your symptoms go away?
Quality
How would you rate the severity of your symptoms?

7. Common Eye Problems Flashes of light Floaters Halos around lights
Double vision
Headaches
How often do they occur?
How would you rate their severity?
Eye pain
Redness
Tearing

8. Visual Demands Occupation Reading Computer
What kind of work do you do?
Reading
Do you read?
Computer
Do you use the computer?
How many hours per day?
How many days per week?

9. Visual Demands Driving Hobbies Sports Do you drive?
Do you have problems driving at night?
Hobbies
What are your hobbies?
Sports
What type of sports do you play?

10. Ocular History Last eye examination (LEE) Last prescription (LRx) Time
When was your last eye examination?
Location
By whom?
Particular exam findings
What was the outcome of that examination?
Last prescription (LRx)

11. Ocular History Glasses Age Usage Vision Comfort
When were your glasses last changed?
Usage
Are they for distance, intermediate, near, or all?
Vision
Describe your vision with your glasses.
Comfort
Describe your comfort with your glasses.

12. Ocular History Contact lenses Average wearing time (AWT)
What is your average wearing time per day?
Wearing time today (WTT)
How long have you worn your lenses today?
Current lens type
What type of lenses do you wear now?
Current lens care regimen
Describe your current lens care regimen, including the solution brand.

13. Ocular History Contact lenses Age Usage Vision Comfort
How old are your current lenses?
Usage
Are they for distance? Intermediate? near? or all?
Vision
Describe your vision with your contact lenses.
Comfort
Describe your comfort with your contact lenses.

14. Ocular History Ocular diseases Ocular surgeries
Have you ever been told that you have an eye turn or a lazy eye?
Have you ever been told that you have cataracts (CAT), glaucoma (GLC), or any other eye disease?
Ocular surgeries
Have you ever had any eye surgeries?

15. Medical History Last physical examination (LPE) Systemic diseases Time
When was your last physical examination?
Location
By whom?
Particular exam findings
What was the outcome of that examination?
Systemic diseases
Have you ever been told that you have diabetes mellitus (DM), high blood pressure (HTN), thyroid disease, heart disease, or any infectious disease?

16. Family History Many diseases are highly genetic in nature
Specifically ask the patient if any of his family members has diabetes mellitus (DM), high blood pressure (HTN), glaucoma (GLC), strabismus, legal blindness/low vision, or any other disease
Record the family member that has each particular disease