Case History Taking Practice
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41 Terms
Demographics
Reason for Visit / CC
HPI
Past Ocular History
Past Medical History
Family History
Medications & Allergies
Social/Occupational History
Case History Form Section
Demographics
Name (or initials for privacy), age, sex, occupation
Reason for Visit / CC
In their own words — why would they be "seeing the doctor" today?
History of Present Illness (HPI)
Apply OLDCARTS: Onset, Location, Duration, Character, Aggravating/Alleviating factors, Radiation, Timing, Severity
Onset
Location
Duration
Character
Aggravating/Alleviating factors
Radiation
Timing
Severity
OLDCARTS
Onset
When did it start? (OLDCARTS)
Location
Which eye? Left, right, or both? (OLDCARTS)
Duration
How long does it last? (OLDCARTS)
Character
What does it feel like? Blurry? Painful? Burning? (OLDCARTS)
Aggravating/Alleviating
What makes it worse? What makes it better? (OLDCARTS)
Radiation
Does the discomfort spread anywhere else? (OLDCARTS)
Timing
Does it happen every day? Morning? Night? Occasionally? (OLDCARTS)
Severity
Rate it from 1–10. (OLDCARTS)
Past Ocular History
Glasses/contacts? Eye surgeries or injuries? Childhood eye problems?
Past Medical History
Diabetes, hypertension, thyroid issues, other major conditions?
Family History
Any glaucoma, AMD, retinal detachment, strabismus, or amblyopia in their relatives?
Medications & Allergies
Current medications (eye or systemic), known allergies.
Social/Occupational History
Job visual demands, screen time, smoking, hobbies.
Px
Patient
CC
Chief Complaint
RFV
Reason for Visit
DV
Distance vision
NV
Near vision
OD / OS / OU
Right eye / Left eye / Both eyes
OH
Ocular history
FOH
Family ocular history
GH
General health
FMH
Family medical history
LEE
Last eye examination
LME
Last medical examination
H/as
Headaches
Sxs
Symptoms
Rx
Prescription / spectacles
CLs
Contact lenses
meds
Medications
With
c̅
Without
s̅
NAD
No abnormality detected
WNL
Within normal limits
b.i.d.
Twice a day
o.d.
Once daily