OPHTALMOLOGY STATUS

A. Patient Identity
1. Name : _________________________________________
2. Sex : _________________________________________
3. Age : _________________________________________
4. Address : _________________________________________
5. Ethnic : _________________________________________
6. Occupation : _________________________________________
7. Religion : _________________________________________
8. Date of consult : _________________________________________
B. Chief complaint :
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C. History of Present Illness:

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D. Past Medical History:

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E. Family History:
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F. General Physical Assessment

1. General Condition : _________________________________________
2. Awareness : _________________________________________
3. Vital Signs
Heart Rate : _________________________________________
Respiration freq. : _________________________________________
Blood Pressure : _________________________________________
Temperature : _________________________________________
G. Ocular Exam:
1. Visual Acuity :
OD : _____________________________________________________
OS : _____________________________________________________
2. Pupils
OD : _____________________________________________________
OS : _____________________________________________________
1. Eye movement :
3. Eye Movement :

4. Intraocular Pressure: _________________________________________

5. Confrontation Visual Fields: ____________________________________
6. Funduscopy:

OD OS
Orthoforia Eye ball Orthoforia
position
Ptosis ( ), Lagoftalmos ( ), Palpebra Ptosis ( ), Lagoftalmos ( ),
Hiperemis ( ), Oedem( ) Hiperemis ( ), Oedem ( )

Redness ( ), Discharge ( ), Conjunctiva Redness ( ), Discharge ( ),

Injection ( ), Chemosis ( ), Bulbi Injection ( ), Chemosis ( ),
Ulcer ( ), Foreign Body ( ) Ulcer ( ), Foreign Body ( )

Membran ( ) Conjunctiva Membran ( )

Tarsal

Cornea

Anterior
Chamber
 Iris and
pupil

Lens

Vitreous

Fundus

H. Diagnosis
Working Diagnosis
Systemic disease: _______________________________________________
Eye disease
OD : _____________________________________________________
OS : _____________________________________________________
Differential Diagnosis
OD : _____________________________________________________
OS : _____________________________________________________
I. Treatment
Non Medikamentosa :
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Medikamentosa :
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Prognosis
Ad vitam : _______________________________________________
Ad functionam : _______________________________________________
Ad sanactionam : _______________________________________________