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
1
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
Referral? Yes
No
Date of Examination
Chief Complaint/Purpose of Visit:
Entering Vision:
OD
(VA
OS
(VA
Uncorrected
/
)
/
)
Refraction:
OD
(VA
OS
(VA
/
/
Pupils:
Glasses
Contact Lenses
Other
)
)
Extraocular Muscles:
2
Anterior Segment
OD
OS
Lids/Lashes
Bulbar Conjunctiva
Palpebral Conjunctiva
Sclera
Cornea
Anterior Chamber
Iris
Lens
Intraocular Pressure:
OD
OS
at
Goldmann
(time)
Visual Field: OD
OS
Dilation drops? Yes
No
Tonopen
NCT
Other
Type:
Posterior Segment
OD
OS
Optic Nerve
C/D
Foveal Reflex
Macula
Posterior Pole
Vasculature
Periphery
Vitreous
Additional Testing (Images, topography, OCT, etc)
Assessment:
Plan:
3
Contact Lens Fitting
Visit #
of
Date of Examination
Chief Complaint/Purpose of Visit:
Entering Vision:
OD
(VA
OS
(VA
Uncorrected
/
)
/
)
Glasses
Contact Lenses
Other
Anterior Segment Notes:
OD
OS
Trial Lens Design:
Length of time trial lens settled before fit assessment:
OD
Trial #
of
Base Curve
Sagittal Depth
Diameter/OZ
Power
Standard
Peripheral Curves
Modified:
Fit Description
Over-Refraction
VA
(Images or other notes can be added here)
OS
Standard
Modified:
(Copy and paste as many of the above trial lens tables as needed)
Ordered Lens Design:
OD
Standard
Modified:
Lens Order
Base Curve
Sagittal Depth
Diameter/OZ
Power
Peripheral Curves
OS
Standard
Modified:
Material
(Images or other notes can be added here)
Assessment:
Plan:
4
Visit #
of
Date of Examination
Chief Complaint/Purpose of Visit:
Entering Vision:
OD
(VA
OS
(VA
Uncorrected
/
)
/
)
Glasses
Contact Lenses
Other
Lens Design:
OD
Standard
Modified:
OS
Base Curve
Sagittal Depth
Diameter/OZ
Power
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
Solution Recommended for Cleaning/Disinfection/Storage:
Solution Recommended for Filling Lens:
Additional Instructions to Patient:
New Lens Order? Yes
No
No
Lens Design:
OD
Standard
Modified:
Lens Order
Base Curve.
Sagittal Depth
Diameter/OZ
Power
Peripheral Curves
OS
Standard
Modified:
Material
(Images or other notes can be added here)
Assessment:
Plan:
5
Visit #
of
Date of Examination
Chief Complaint/Purpose of Visit:
Entering Vision:
OD
(VA
OS
(VA
Uncorrected
/
)
/
)
Glasses
Average Comfortable Wearing Time:
Lens Design:
OD
Contact Lenses
Other
Wearing Time On Day of Visit:
OS
Base Curve
Sagittal Depth
Diameter/OZ
Power
Peripheral Curves
Standard
Modified:
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
Standard
Modified:
Lens Order
Base Curve.
Sagittal Depth
Diameter/OZ
Power
Peripheral Curves
OS
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)
6
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
7
References
Add references here (should include peer-reviewed journal articles)
8