Ophthalmology Long Case Name: Age: Gender: Address: Occupation: Date of History Taking: Chief Complaint and Duration: __________________________________________________________ History of Present Illness: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________ Past Medical History: __________________________________________________________ __________________________________________________________ Drug History: __________________________________________________________ __________________________________________________________ Past Surgical History: __________________________________________________________ __________________________________________________________ Family History: __________________________________________________________ __________________________________________________________ Social History: __________________________________________________________ __________________________________________________________ __________________________________________________________ __________________________________________________________