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Page 7 text:
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ILLINOIS COLLEGE OF OPTOMETRY RECORDQ GENERAL CLINIC EXAMINATION DATE NAME Age Birth date Ref by last first Address . catyfsiaie zap Phone lntern Box Room Module Chief Complaintlsl I Ocular Symptoms Fully investigate positive responses Blur 1 Diplopia I Pain Photophobia Headaches Ocular fatigue Halos Secretions ' sr -s 'I 'F lll l'0lll Itching Rubs eyes Burning F-t Loses place -- J L A N L Tearing P-0 Holds things close g Blinking Head tilt Squinting Other problems General Health Condition of General Health Last complete physical exam mo I Result , Diabetes Sinusitis --- ---' H Hypertension Past medical . Allergies problems MedicationsfBCP Idosagel Thyroid ' Ocular History Last vision exam 8- results f Previous Eye Doctor Eye diseases,injuries.surgery . or other visual problems BirthfDev Hx R, used presently Y N How old When' used Effectiveness CL used presently Y N How old Type Effectiveness Other comments I Family History Glaucoma Learning disabilities Cataracts Hypertension Suabismus Vision problems Blindness Other conditions Diabetes Visual Demands Occupation Working distances 3, visual environment Avocation 8- visual demands Educational Hx Student grade level Achievement level
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