Name: Date / / Time

CC: R___L___BOTH_____
 

S.
 

History	YES	NO	DESCRIBE
Discharge
Pain
Itching
F.B. Sensation
Visual changes
Recent URI
Expos. to conj.
Allergy symtoms
Seasonal allergies
Contact lenses
Other

Current Meds:
 

Med. Allergies: Environment:

O:
 

Physical	WNL	ABN	DESCRIBE
Visual Acuity			N/A Snellen: RT LT
Sclera/conj.
Discharge
PERRLA
Photophobia
EOM
Fundiscopic
Flour. Stain
Other

A: Conjunctivitis (viral, bacterial, allergic) Corneal abrasion Foreign body
 

OTHER
 

P: ____ Sod. Sulface.10% Sol. q 2-3 hrs. X 5 - 7 days ____ Polytrim ophth. (tri/sulf) 1 gtt Q 3 X 7-10 days

____Garamyacin Ophth. Sol. q 4 hrs. X 5 - 7 days ____ Acular Ophth. 1 gtt QID

____ Antihistamine ____ Compresses (warm/cold)

____ Referred: ER OPHTHO : Name________________________________________Date___________Time_______

____ F/U

____Other
 

REV: 8/97 MAP Signature /CLINIC /EYES.CCK