Eye Ear Nose Exam

Eye, Ear, Nose & Throat Exam
Check normal, circle & describe abnormal

Patient:_______________________________________________ Date: __________________ Date of birth: _______________ M/F _____________________________________________________

CC & significant history: ____________________________________________________ __________________________________________________________________________ Temp: __________, Pulse: _______, Resp: _________, BP: L: _____/_____, R: _____/_____

Eye:: □ WNL □ Visual acuity: L: _______/_______ R: _______/_______ □ corrected, □ uncorrected External inspection □ Size, shape symmetry: ____________________________ □ Lids, lashes: ____________________________________ □ Conjunctiva (pallor):: ______________________________ □ Iris, sclera, cornea:: _______________________________ □ Palpation: ______________________________________ Examination □ Ocular movements: _______________________________ □ Visual fields: ____________________________________ □ PERRLA:: _______________________________________ □ Corneal reflex:: ___________________________________ □ Cover/uncover test: _____________________________ ______________________________________________ _______________________________________________

Ear:: □ WNL □ Uncorrected, □ hearing aid External inspection □ Size, shape symmetry: ______________________________ □ Position & alignment of head:: _________________________ □ Skin condition (color, lumps, lesions):: ___________________ □ Auricular & tragus movement:: _________________________ □ External auditory meatus: ____________________________ □ swelling, □ redness, □ discharge, □ cerumen Examination □ Watch test: L > = < R ________________________________ □ Weber: =, lateralize L/R ______________________________ □ Rinne:: AC > = < BC ________________________________ □ Vestibular function:: _________________________________ □ Swivel chair test: test: _______________________________

Right

Ophthalmic exam

Left

□ Red reflex □ Optic cup & disc □ Disc margins well defined □ Cup:disc ratio (1:2) □ buldging □ cupping □ Trace blood vessels □ Macula □ Anterior chamber _________________________________________ _________________________________________ ________________________________________

_____________________________________________________________ _____________________________________________________________ _____________________________________________________________

Otoscopic exam □ Auditory canal □ Tympanic membrane □ Irritation □ Scarring □ Perforation □ Cone of light □ Red reflex □ Fluid level: _______________________ □ Discharge: _______________________ Pneumatic otoscopy □ Brisk movement □ Slow/absent movement ________________________________________ ________________________________________

Nose:: □ WNL External inspection □ Size, shape symmetry: _________________________________________ □ Skin condition : _______________________________________________ □ Deviated septum:: ______________________________________________ □ Congestion:: __________________________________________________ Rhinoscopic examination □ Color: _______________________________________________________ □ Discharge: ___________________________________________________ □ Ployps:: ______________________________________________________ Sinus examination □ Percussion:: __________________________________________________ □ Transillumination: ______________________________________________ _____________________________________________________________ _____________________________________________________________

Left

Right

Throat:: □ WNL □ Size, shape symmetry: ___________________ ________________________________________ ________________________________________ □ Lips: _________________________________ □ Mucos Mucosaa □ Buccal: _____________________________ □ Labial : _____________________________ □ Teeth: ________________________________ ________________________________________ ________________________________________ □ Tonsils: _______________________________ ________________________________________ □ Pharynx: ______________________________ ________________________________________ □ Tongue:: _______________________________ ________________________________________ ________________________________________ □ Uvula:: ________________________________ □ Hard palate: ___________________________ □ Gingiva: _______________________________ ________________________________________ □ Cervical lymph nodes: ___________________ ________________________________________ Other: __________________________________ ________________________________________ ________________________________________ ________________________________________

This form is a comprehensive checklist of examination procedures. Each item should be utilized as a diagnostic option based on the patient’s presenting symptoms and the clinical discretion of the examiner. Every procedure does not have to be performed on every patient. Some procedures may be contraindicated in certain situations. Patient information contained within this form is considered strictly confidential. Reproduction is permitted for personal use, not for resale or redistribution. www.prohealthsys.com ©2005 by Professional Health Systems Inc. All rights reserved. “Dedicated to Clinical Excellence.”

Signature:

Date: