Ophthalmic History Taking

The chief complaint is the patient's primary reason for the visit. It is the single most important piece of information gathered during the history — it drives the entire examination and clinical decision-making. Record the CC as a brief, specific statement: 'blurry vision in the right eye for 2 weeks' is far more useful than 'eye problem.' Always ask open-ended questions first: 'What brings you in today?' or 'How can we help you?' Let the patient speak without interruption for the first 30-60 seconds. If the patient has multiple complaints, identify and prioritize the most urgent or bothersome issue. Common ophthalmic chief complaints include: decreased vision (distance or near), eye pain or discomfort, redness, discharge, floaters, flashes of light, double vision, tearing, itching, foreign body sensation, and eyelid swelling. The CC should always include laterality (which eye), symptom description, and duration.