Personal Injury Eye Evaluation

Patient Evaluation and Medical History

Patient Name (Last, First):

Date of Exam:

Date of Injury:

Attorney Name:

Attorney Fax Number:

Age:

Sex: Male Female

Marital Status: Single Married Divorced Widowed

Date of Birth: Ethnicity: Occupation: Hobbies: Who referred you to Dr. Malitz? Current Medical Doctor: Reason for this Visit:

Injury History

Date and time of injury: Mechanism of injury (e.g., blunt trauma, chemical exposure, foreign body): Detailed description of injury: Immediate symptoms after injury: Treatments received since injury:

Use of protective eyewear at time of injury: Yes No

Previous similar injuries (if yes, explain):

Patient Ocular History

Date of last eye exam: Doctor's name:

Have you ever been prescribed corrective lenses? Yes No

How long ago? Do you currently wear:

Glasses Contacts Both None

How often do you wear them?

Full Time Part Time

Special vision tasks at work or home: Known Eye Diseases (list dates and which eye involved): Previous Eye Operations (list dates and which eye involved): Previous Eye Injuries (list dates and which eye involved):

Past Medical History

Diabetes: Yes No

If yes, how long?

Heart Disease: Yes No

If yes, how long?

High Blood Pressure: Yes No

If yes, how long? Collagen Vascular Disease (Lupus, Arthritis, Crohn’s, etc.): Other Medical Conditions: Allergies to Medicines: Eye Medications:

Family History (blood relatives only)

Retinal Detachment: Yes No

Blindness: Yes No

Glaucoma: Yes No

Diabetes: Yes No

Macular Degeneration: Yes No

Heart Disease: Yes No

Social History

Smoking History: Yes No

If yes, how long? Packs per day?

Alcohol / Drug History: Yes No

If yes, how long? Amount:

Review of Systems & Symptoms

System	No	Yes	Details / Comments
Constitutional (Fever, Weight Loss/Gain)
Loss of Vision
Blurred Vision
Distorted Vision
Loss of Side Vision
Double Vision
Dryness
Redness
Foreign Body Sensation
Eye Pain or Soreness
Flashes/Floaters in Vision

Current Medications

Visual Acuity

	Right Eye (OD)	Left Eye (OS)
Without Correction
With Correction
Pinhole VA
Near Vision

External Eye Examination

Structure	Right Eye (OD)	Left Eye (OS)
Eyelids/Lashes/Conjunctiva/Sclera
Pupils (Size/Shape/Reactivity)
Extraocular Movements (Pain/Restriction)

Anterior Segment Examination (Slit Lamp)

Structure	Right Eye (OD)	Left Eye (OS)
Cornea
Anterior Chamber
Iris
Lens

Intraocular Pressure (IOP)

Right Eye (OD):

Left Eye (OS):

Posterior Segment Examination (Dilated Fundus Exam)

Structure	Right Eye (OD)	Left Eye (OS)
Optic Nerve
Macula
Retinal Vessels
Peripheral Retina

Visual Fields

Confrontation Test Results: Automated Perimetry (if available):

Additional Tests (if applicable)

Color Vision Testing: Fluorescein Staining: Imaging Studies (OCT, Ultrasound, CT):