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TELEMEDICINE

Patient’s First Name:?_________________________ Last Name:____________________________
Birthdate: m______/d________/y__________ Today’s date ____/_____/_________
cell phone # (_______)________-_________ email:______________________________________
Name of ( )parent / ( )guardian or ( )who is sending the Telemedicine Exam: ___________________

Health History:

Main Problem/Concern with Vision:___________________________________________________
When did it start?______________________________________
How bad is it?_________________________________________
What makes it worse?___________________________________
What makes it better?____________________________________

( )New Referral or ( )Follow-up
Your doctor / local health-care provider(s)? ____________________________________

Any current treatments for the eye(s)?____________________________
Glasses?: _________________

Any other Health Problems?:

Any "Warning Signs?"

Explain any Injury to the eyes?____________________________

Any Surgery related to the eyes?_______________________

Any Family Vision problems related to the eyes?__________________

Your Examination of the EYES and VISION:

Home Acuity Monitor : right eye: 20/_________ left eye: 20/__________

If you can get a photoscreen from local clinic / nurse / Lion’s Club, send results.

Download Home Exam Guide and tape to patient's neck

Cell phone photograph(s) showing what concerns you about the eye(s).

Cell phone video showing eye alignment or concerns.

( ) Video or observation of Cover Test:

( ) Both index fingers estimate Intraocular Pressure (IOP of a Grape video): _____ R_______ L

Comments:

http://www.abcd-vision.org/abcd-clinics/Telemedicine.html

ABCD History

Kids Eye Disorders

Amblyopia

Vision Screening

Issues

ABCD Clinics

References

Contact ABCD

Alaska Children's EYE