04 Taking A Case History

INTRODUCTION TO OPTOMETRY
Taking a case history

Authors
Brien Holden Vision Institute Faculty
Sydney, Australia
Peer Reviewer
Bob Chappell
Past President: World Council of Optometry (WCO)
Project Director, Editor-in-Chief

Luigi Bilotto
Brien Holden Vision Institute, Public Health Division, Durban, South Africa
University of Montreal, Quebec, Canada

Associate Editor
Pirindhavellie Govender
Brien Holden Vision Institute, Public Health Division, Durban, South Africa
University of KwaZulu Natal (UKZN) Durban, South Africa

Technical Editors
Elaine Quinn

Layout Editors
Rajni Chhabra, Prashant Kumar

Graphics
Shane Parker
Brien Holden Vision Institute Foundation (formerly ICEE) is a Public Health division of Brien Holden Vision Institute
COPYRIGHT © 2010 Brien Holden Vision Institute. All rights reserved.
This publication is protected by laws relating to copyright. Except as permitted under applicable legislation, no part of this publication may be adapted, modified, stored in a retrieval system, transmitted or reproduced in any form or by any process, electronic or otherwise,
without the Brien Holden Vision Institute’s (The institute) prior written permission. You may, especially if you are from a not-for-profit organisation, be eligible for a free license to use and make limited copies of parts of this manual in certain limited circumstances. To see if you
are eligible for such a license, please visit http://education.brienholdenvision.org/ .
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The material and tools provided in this publication are provided for purposes of general information only. The Institute is not providing specific advice concerning the clinical management of any case or condition that may be mentioned in this publication, and the information
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Learning outcomes
• State what taking a history is and why it is

important
• Describe the things you need to ask about a
person’s eyes and their vision
• Describe the things you need to ask about a
person’s general health and lifestyle
• Perform a case history
• Use good communication skills when taking
a case history
Finding out if there is a problem
1. Symptoms
Ask the person about their eyes and how well they see
Finding out if there is a problem
2. Visual acuity
Measure how well the

person can see
Finding the problem
3. Signs
Look carefully at their eyes

What is a case history?
• A person comes to see you with a problem

about their eyes or their health
• You will need to ask questions to find out
what the problem is
• The questions you ask may be about their
eyes, their general health and their lifestyle
• These questions and the answers the person
provides you with make up the case history.
When do you take a case history?
• At the start of the eye examination

• It can continue throughout the examination
• especially if your testing reveals new
information
• The only time when we do not take the
case history first, is when there is an eye
emergency
• such as a chemical burn of the cornea
Why do we take a case history?
A case history helps you to find out:

• the problem the person is presenting with
• if the eye problem is getting better or worse
• which tests need to be performed
• what action needs to be taken
You may then need to:

• treat the eye problem
• refer the person
• talk to the person and/or their community about
the spread of the eye disease and provide education
on eye care
Case history
• Often, a good case history is more helpful in

diagnosing a person’s eye problem than the
tests that you do
Taking a case history
• Chief Complaint
• Eye health
• Eye history
• General health
• Medical and Family history
Chief complaint
• The chief complaint (CC) is the main reason the person

comes to you
• It tells us the main problem the person is having
Chief complaint
• Always investigate the chief complaint during

the eye examination
• Discuss your findings at the end of the
examination
• Always try to do something about the chief
complaint
• For example, a woman’s chief complaint might
be that she cannot see close up to do her sewing;
so we should try to provide her with spectacles that
will give her good near vision
Chief complaint
Asking for details

• When did the problem first start?
• Did it happen gradually or suddenly?
• Is it getting better or worse?
• Is it there all of the time or only sometimes?
• How long has it been happening for?
• Is it with one eye or both eyes?
• Has your vision changed?
Chief complaint
Asking for details

• How do your eyes feel?
(for example, irritated, itchy, sore)
• Do you have pain?
• If so, what is it like?
(dull, sharp)
• Where is the pain?
• Do you have any other symptoms when
you get the pain?
Chief complaint
Asking for details

• Have you noticed if your eyes look different?
(red, swollen)
• Have you done anything about the problem,
seen anyone else or tried any other treatment?
• Does anyone else you know have the same
problem?
• Is there anything more you can tell me about
this problem?
Eye health
• Vision
• Flashes and Floaters
• Eye health
• Visual Needs
Eye health
Vision:
• To find out how well
a person sees,
you should ask:
• How is your vision when
you look far away?
• How is your vision when
you read books or look
at things up close?
Eye health
Flashes and floaters

The questions you might ask include:
• Do you ever see floating spots or flashing lights
in your vision?
• When do you see them?
• Have they changed in size?
• Are you seeing more floaters
now than before?
• Did you have an injury to your
eye or your face?
Eye health
• Questions you might ask a person about

their eye health include:
• Do you have red, sore, itchy eyes?
• Do you get headaches?
Eye health
Visual needs
•To find out what the person’s visual needs are, you
should ask about:
• The work they do
(e.g. computer use, drawing, driving)
• Their hobbies
(e.g. art, sewing, reading, fishing)
• Any sports they play
Eye history
• Last eye test

• Spectacles
• Headaches
• Eye history
Eye history
Last eye test

• Have you ever had an eye examination
or eye test?
• If yes, how long has it been since your
last eye test?
Eye history
Spectacles
• Do you have spectacles, or have you ever
worn spectacles before?
• If the person has had spectacles:
• What tasks do you wear your spectacles for?
• How old are the spectacles?
• How well do you see with the spectacles?
• Are you happy with your spectacles?
• If not, what is the problem?
Eye history
Headaches
• Do you get headaches or eyestrain?
• When do the headaches or eyestrain start?
• How long does it last?
• Show me where on your head the pain is
• Are the headaches worse in the morning or afternoon?
• Does the headache go away after you’ve had a sleep?
• How bad is the headache? (Scale)
• Do you have any other symptoms with the headache
(e.g. vomiting/ flashes of light)
Eye history
• Do you have any eye conditions

or diseases like cataract, trachoma
or glaucoma?
• Have you ever had any eye injuries
or infections?
• Have you ever had any surgery
on your eyes?
• Have you ever used any eye drops
or medication for your eyes?
General health and medical history
• Asking about the general health

of the person can help us find
out what is wrong with their eyes
• It can also help us plan
their treatment
• Many eye problems develop due
to eye injuries or eye treatment
as well as diseases in other parts
of the body.
General health and medical history
• How is your general health?

• Are you seeing a doctor for anything
at the moment?
• Are you using any medications?
(name, dosage, use)
• Do you have any allergies?
(e.g. sulphur, antibiotics)
• Do you have high blood pressure,
diabetes or abnormal blood sugar?
• Are you pregnant?
Family history
• Some eye problems are more common

in some families than others
• It is important to know about eye problems
in a person’s family
Family history
• Does anybody in your family have

health problems?
• Does anybody in your family have
eye problems?
• Record these details
Communication skills
• Important to get correct and helpful

information from a person
• Show the person you care about them
and their eyes
• Gain their confidence
Good communication skills
• Greet the person and introduce yourself in

a friendly way
• Show the person where to sit and sit

facing them
Listen carefully to what the person tells you
Use words the person will understand

Give them enough time to answer

your questions
Ask questions in an
organised and logical way
Open-ended questions require the person to think

about the question, and describe what they think
or how they feel
WHEN?
WHAT?
HOW? DESCRIBE

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INTRODUCTION TO OPTOMETRY

Taking a case history

Project Director, Editor-in-Chief

COPYRIGHT © 2010 Brien Holden Vision Institute. All rights reserved.

• State what taking a history is and why it is

Measure how well the

Look carefully at their eyes

• A person comes to see you with a problem

• At the start of the eye examination

A case history helps you to find out:

You may then need to:

• Often, a good case history is more helpful in

• The chief complaint (CC) is the main reason the person

• Always investigate the chief complaint during

Asking for details

Asking for details

Asking for details

Flashes and floaters

• Questions you might ask a person about

• Last eye test

Last eye test

• Do you have any eye conditions

• Asking about the general health

• How is your general health?

• Some eye problems are more common

• Does anybody in your family have

• Important to get correct and helpful

• Greet the person and introduce yourself in

• Show the person where to sit and sit

Listen carefully to what the person tells you

Use words the person will understand

Give them enough time to answer

Open-ended questions require the person to think

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