Initial Evaluation

OVERALL_INSTRUCTIONS

Chief Complaint

[Description of Presenting Complaint]

Template

Dear Dr [Referring Physician Name], Thank you for referring [Patient Name], a [Patient Age in months/years]-old [Sex], who was seen on [Date (YYYY-MM-DD)]. Presenting Complaint: [Description of Presenting Complaint] History of Presenting Complaint: [History of Presenting Complaint] Past Ocular History: [Past Ocular History] Past Medical History: [Past Medical History] Family History: [Family History] Current Medications: [Current Medications] Allergies: [Allergies] On Examination Visual Acuity: [Visual Acuity] [Stereopsis: [Stereopsis]] [Cover Test (0.3m): [Cover Test at 0.3 meters]] [Cover Test (6.0m): [Cover Test at 6.0 meters]] [Extraocular Movements: [Extraocular Movements]] Lids and Adnexa: [Lids and Adnexa] Conjunctiva: [Conjunctiva] Cornea: [Cornea] Anterior Chamber: [Anterior Chamber] Lens: [Lens] Dilated with cyclopentolate 1% both eyes or dilated with cyclopentolate 0.5% phenylephrine 2.5% both eyes or undilated. Right Disc, Macula, and Peripheries: [Right Disc, Macula, and Peripheries] Left Disc, Macula, and Peripheries: [Left Disc, Macula, and Peripheries] Intraocular Pressure: [Intraocular Pressure] Cycloplegic Refraction: [Cycloplegic Refraction] Impression 1. [Impression] Plan 1. [Plan] Thank you for the opportunity to be involved in the care of [Patient Name]. Where ongoing care has been arranged, this has been made by implicit re-referral for consultation. Please let me know if you do not feel this is indicated. Yours sincerely, [insert physician's name]