Optometry Note Full Consult

**Presenting Complaint** [Describe the patient's primary reason for the visit, including symptoms, onset, duration, and any associated factors, using dot points and ordering them by priority or most important complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Hobbies/Work/School** - [Provide 1–2 dot points describing the patient's hobbies, work, or school activities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Systems Review** [Describe presence or absence of symptoms across relevant ocular systems: headache, dryness, redness, itchiness, diplopia, flashes, floaters. If no symptoms are reported across all systems, output "Nil HA, Dry, Red, Itchy, Dip, Flash/Floaters"] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **General Health** - [Document the patient's general health status, including systemic conditions, allergies, and relevant medical history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Past Ocular History** - [Detail any previous ocular conditions, surgeries, or treatments] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Family Ocular** - [Record any relevant ocular conditions reported in the patient's family history] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Anterior Assessment** Lids/Lashes/Conj/Cornea/Iris/Lens: [Describe the appearance and condition of the eyelids, lashes, conjunctiva, cornea, iris, and lens for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) VH: [Describe the anterior chamber volume for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) AC: [Describe the anterior chamber activity for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Posterior Assessment** ONH c/d: [Document the optic nerve head cup-to-disc ratio and appearance, including the neuroretinal rim and margins for both eyes, including whether they are pink, healthy NRR, and well-defined margins] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Mac: [Describe the macula health and flatness for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) BVs: [Describe the retinal blood vessels] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) Mid-periphery: [Describe the mid-periphery appearance for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Dispensing Options** [List and describe the dispensing options discussed, including single vision distance (SVD), single vision near (SVN), or multifocal (MF) lenses] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Binocular Vision Assessment** [Detail the findings and assessments related to binocular vision, if performed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Contact Lens Assessment** [Document any complaints related to contact lens wear, usual wear time, and cleaning regimen] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Visual Fields** [Document the findings of the visual field assessment] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **OCT** [Document the findings of the Optical Coherence Tomography, including sections for RNFL, GCC, and Mac radial] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **IOP** [Document the intraocular pressure readings for both eyes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Advice & Management** - [List all advice given and the management plan in a numbered, bullet-point format, using abbreviations where appropriate] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) **Other** [Document any other important notes or relevant details that do not fall under the existing headings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript. Use abbreviations wherever possible.)