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Ahmad Abid bin Abas 07-5-2
Ahmad Asyraf bin Mohamed 07-5-3
   Preparation
   Brief Introduction of yourself to patient
   Confidentiality
   Documentation
   Communication
   Personal Data :
    - Name (for identification, filing system, friendly)
    - Age (age related diseases-child : congenital
    diseases, old : senile diseases)
    -Sex (sex related diseases)
    -Address (endemic diseases, social status)
    -Occupation (occupation related diseases, visual
    needs)
   Chief Complain (c/o) :
    - in Arabic/Malay , in patient’s words
    -don’t forget duration of c/o
    -don’t use diagnostic words.
    -return and correct unrelated complaints
    -if more than one, arrange by chronological
    and by importance.
   Type of complaints :

    1) Visual complaints :
    -(sudden loss of vision, diminution of
    vision, blurring, photophobia etc..)
    2) Non-Visual complaints :
    -(discharge, pain, itching, swelling etc..)
1)       Describe each complaints in scientific words
2)       Analyse each complaints as regards;
     ◦   Onset
     ◦   Course
     ◦   Side
     ◦   Duration
     ◦   Associated symptoms
     ◦   Previous medical advice and medication
1) Ask if similar or related problems have
existed before.
-Chronological order the major illness and
major operations
- previous eye surgery
2) Past use of medications.
3) History of previous glasses.
4) Diabetes Mellitus and Hypertension
5) Systemic Illness
Ask if any other member of the family have
similar condition or other eye related diseases.

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Patient history documentation guide

  • 1. Ahmad Abid bin Abas 07-5-2 Ahmad Asyraf bin Mohamed 07-5-3
  • 2. Preparation  Brief Introduction of yourself to patient  Confidentiality  Documentation  Communication
  • 3. Personal Data : - Name (for identification, filing system, friendly) - Age (age related diseases-child : congenital diseases, old : senile diseases) -Sex (sex related diseases) -Address (endemic diseases, social status) -Occupation (occupation related diseases, visual needs)
  • 4. Chief Complain (c/o) : - in Arabic/Malay , in patient’s words -don’t forget duration of c/o -don’t use diagnostic words. -return and correct unrelated complaints -if more than one, arrange by chronological and by importance.
  • 5. Type of complaints : 1) Visual complaints : -(sudden loss of vision, diminution of vision, blurring, photophobia etc..) 2) Non-Visual complaints : -(discharge, pain, itching, swelling etc..)
  • 6. 1) Describe each complaints in scientific words 2) Analyse each complaints as regards; ◦ Onset ◦ Course ◦ Side ◦ Duration ◦ Associated symptoms ◦ Previous medical advice and medication
  • 7. 1) Ask if similar or related problems have existed before. -Chronological order the major illness and major operations - previous eye surgery 2) Past use of medications. 3) History of previous glasses. 4) Diabetes Mellitus and Hypertension 5) Systemic Illness
  • 8. Ask if any other member of the family have similar condition or other eye related diseases.