History of Present Illness | Red Eye Emergency

Patient

First Name Last Name

Please answer the following questions:

Which eye is affected? Right Left Both

Which part of the eye is affected? Entire Eye White Part Colored Part Eyelids Eyebrow Eyelashes

What's happening to the eye? Pain Redness Discharge Tearing Itching Other

What's the level of severity? Mild - 1 2 3 4 5 6 7 8 9 10 - Unbearable

How long do the symptoms last? 5 min or less 5 to 15 min 15 to 60 min 60 min or more Not Applicable

When did the problem start? Today Yesterday 3-6 days ago 1-3 weeks ago 1 month ago > 1 month

What were you doing when you noticed the problem?

Have you tried anything to make the problem go away? No Yes

Does anything else happen at the same time, such as headaches or nausea? No Yes