Form-Based Case Report

Name:

Email:

Address:

Case Report #: of

Instructions: Type in grey boxes with pertinent information. To “x” a checkbox, double click on the box and select “checked” under default value.Images should be included where appropriate. Highlighted areas are instructional and can be deleted for the final report.

Title

Introduction

Summary of ocular condition and case report

Case Report

Patient Demographics & History

Patient initials:
Patient age, race, and gender:
Occupation:
Personal ocular history:
Personal medical history:
Current medications:
Drug allergies:
Family ocular history:
Family medical history:
Other notes:

Examination Findings

Visit # of Date of Examination
Referral? Yes No
Chief Complaint/Purpose of Visit:
Entering Vision: Uncorrected Glasses Contact Lenses Other
OD (VA /)
OS (VA /)
Refraction:
OD (VA /)
OS (VA /)
Pupils: Extraocular Muscles:

Anterior Segment

OD / OS
Lids/Lashes
Bulbar Conjunctiva
Palpebral Conjunctiva
Sclera
Cornea
Anterior Chamber
Iris
Lens
Intraocular Pressure: Goldmann Tonopen NCT Other
OD OS at (time)
Visual Field: OD OS Type:
Dilation drops? Yes No

Posterior Segment

OD / OS
Optic Nerve
C/D
Foveal Reflex
Macula
Posterior Pole
Vasculature
Periphery
Vitreous

Additional Testing (Images, topography, OCT, etc)

Assessment:
Plan:

Contact Lens Fitting

Visit # of Date of Examination
Chief Complaint/Purpose of Visit:
Entering Vision: Uncorrected Glasses Contact Lenses Other
OD (VA /)
OS (VA /)
Anterior Segment Notes:
OD
OS
Trial Lens Design:
Length of time trial lens settled before fit assessment:
OD / Trial # of / OS
Base Curve
Sagittal Depth
Diameter/OZ
Power
Standard
Modified: / Peripheral Curves / Standard
Modified:
Fit Description
Over-Refraction
VA
(Images or other notes can be added here)
(Copy and paste as many of the above trial lens tables as needed)
Ordered Lens Design:
OD / Lens Order / OS
Base Curve
Sagittal Depth
Diameter/OZ
Power
Standard
Modified: / Peripheral Curves / Standard
Modified:
Material
(Images or other notes can be added here)
Assessment:
Plan:
Visit # of Date of Examination
Chief Complaint/Purpose of Visit:
Entering Vision: Uncorrected Glasses Contact Lenses Other
OD (VA /)
OS (VA /)
Lens Design:
OD / OS
Base Curve
Sagittal Depth
Diameter/OZ
Power
Standard
Modified: / Peripheral Curves / Standard
Modified:
Material
Fit Description
VA
Over-Refraction (VA)
Anterior Segment Notes:
OD
OS
Application and Removal Successful? Yes No Dispense Lenses? Yes No
Solution Recommended for Cleaning/Disinfection/Storage:
Solution Recommended for Filling Lens:
Additional Instructions to Patient:
New Lens Order? Yes No
Lens Design:
OD / Lens Order / OS
Base Curve.
Sagittal Depth
Diameter/OZ
Power
Standard
Modified: / Peripheral Curves / Standard
Modified:
Material
(Images or other notes can be added here)
Assessment:
Plan:
Visit # of Date of Examination
Chief Complaint/Purpose of Visit:
Entering Vision: Uncorrected Glasses Contact Lenses Other
OD (VA /)
OS (VA /)
Average Comfortable Wearing Time:Wearing Time On Day of Visit:
Lens Design:
OD / OS
Base Curve
Sagittal Depth
Diameter/OZ
Power
Standard
Modified: / Peripheral Curves / Standard
Modified:
Material
Fit Description
VA
Over-Refraction (VA)
Anterior Segment Notes:
OD
OS
Dispense Lenses? Yes No N/A
Additional Instructions to Patient:
New Lens Order? Yes No
Lens Design:
OD / Lens Order / OS
Base Curve.
Sagittal Depth
Diameter/OZ
Power
Standard
Modified: / Peripheral Curves / Standard
Modified:
Material
(Images or other notes can be added here)
Assessment:
Plan:

(Copy and paste as many of the above follow-up visit templates as needed)

Discussion

Final Diagnosis:
Description of ocular disease:
Describe alternative treatment options:
Describe final treatment option:
Was the patient’s chief complaint resolved? Yes No
Was the patient fit successfully for at least 3 months? Yes No
If answer to either of the previous two questions is “No”, please explain why:

Conclusion

Brief concluding summary

References

Add references here (should include peer-reviewed journal articles)

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