SALAMAT HOSPITAL

EYE EXAMINATION FORM

NAME : : ‫االسم‬ Patient File No.: ‫رقم ملف المريض‬
Age : ‫العمر‬ SEX: M F : ‫الجنس‬ Dept.: : ‫القسم‬ ROOM: : ‫الغرفة‬
Nationality : :‫الجنسية‬ Attending Physician : : ‫الطبيب المعالج‬

Chief Complaint: ………………………………………………………………………………………………………………………………………………………………………..

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Present Illness: ………………………………………………………………………………………………………………………………..………………………………………..

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Past History Including Hospitalization:

Ocular Diseases: …………………………………………………………………………………………………………………………………………………….…………………..

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Trauma: ………………………………………………………………………..…………………………………………………………………………………………………………..
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Treatment: ………………………………………………………………………………………………………………………...……………………………………………………..
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Systemic Diseases: ………………………………………………………………………..……………………………….…………………………………………………………..

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Medications: ………………………………………………………………………………..……………………………………………………………………………………………..
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Allergies: ……………………………………………………………………….……………..……………………………….…………………………………………………………..
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Family History: ………………………………………………………………………..……………………………………..…………………………………………………………..

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OD OD
VA: IOP:
OS OS

SH.OPTHA.F.001.01 Page 1 of 2
 SALAMAT HOSPITAL
EYE EXAMINATION FORM
NAME : : ‫االسم‬ Patient File No.: ‫رقم ملف المريض‬
Age : ‫العمر‬ SEX: M F : ‫الجنس‬ Dept.: : ‫القسم‬ ROOM: : ‫الغرفة‬
Nationality : :‫الجنسية‬ Attending Physician : : ‫الطبيب المعالج‬

Right Eye (O.D) Left Eye (O.S)

Lids, Lacrimal System Lids, Lacrimal System
Conjunctiva Conjunctiva
Cornea AC Cornea AC

Iris Iris
Pupil Pupil
Lens Lens

Vitreous Vitreous

Fundus Fundus

Motility: …………………………………………………………………………………………………...………………………………………………………………………………..
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Diagnosis: …………………………………………………………………………………………………...……………………………………………………………………………..
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Plan: …………………………………………………………………………………………………………...……………………………………………………………………………..
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Physician Name & Signature / Stamp
Date: _____/_____/_____
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