History Taking Clinical Guide

Tools & Materials

Setting Up for an Effective History

1. Review pre-visit information: Before entering the room, review any intake forms, previous records, or referral letters. Note the patient's age, existing diagnoses, and any flagged concerns. This prevents repetitive questioning and allows the history to build on existing knowledge.
2. Introduce yourself: State your name and role. Confirm the patient's name and date of birth (two patient identifiers). In shared-care settings, clarify to the patient whether you are the primary clinician or part of a team.
3. Ensure privacy: The consultation room should afford visual and acoustic privacy. Sensitive information — including driving concerns, mental health, or substance use — requires a private, unhurried environment.
4. Minimise barriers: Sit at eye level with the patient. Avoid a desk as a physical barrier if possible. Maintain open body language. Put the computer screen to the side rather than between you and the patient.
5. Establish the agenda: Ask the patient to list all concerns before beginning a detailed history of any one issue. "Before we start, is there anything else you'd like to talk about today?" — asked early, this prevents the “doorknob moment” where a second important concern emerges at the end of the appointment.
6. Language and health literacy: Use plain language. Avoid jargon unless the patient demonstrates clinical familiarity. Adjust vocabulary to the patient's apparent health literacy. If English is not the patient's primary language, arrange a professional interpreter — do not rely on family members, especially children, for medical interpretation.

Eliciting the Chief Complaint

The chief complaint is the patient's primary reason for attending — stated in their own words. It should be documented as a brief phrase, not a diagnosis. Open-ended questioning is essential at this stage.

Common Chief Complaints in Optometry

Key Areas to Cover

1. Previous spectacles and contact lenses: Current prescription (near, distance, progressive, multifocal)? Satisfaction? When last changed? Contact lens type, modality, wear pattern, cleaning system, compliance with replacement schedule. Any contact lens-related complications?
2. Previous ocular diagnoses: Amblyopia, strabismus, glaucoma, macular degeneration, diabetic retinopathy, uveitis, corneal disease, retinal detachment. When diagnosed? Under whose care? What treatment or monitoring is in place?
3. Ocular surgery: Cataract extraction (IOL type: monofocal, multifocal, toric), refractive surgery (LASIK, SMILE, PRK — when, which eye, any complications), trabeculectomy, vitreoretinal surgery, strabismus surgery, lid procedures. Note: LASIK significantly affects IOP measurement accuracy and IOL calculation if cataract surgery is subsequently required.
4. Amblyopia and strabismus: History of patching? Orthoptic treatment? Was strabismus surgically corrected? What is the current alignment and binocular status?
5. Trauma: Any previous eye injury? Type (chemical, blunt, penetrating, foreign body)? Was it treated? Any residual effects (scarring, reduced vision, lid abnormality)?
6. Ocular medications: Current and recent topical drops — IOP-lowering agents, steroid drops, antivirals, antibiotics, lubricants. Duration of use? Compliance? Any side effects? Topical steroids should prompt IOP monitoring; long-term use of certain drops (brimonidine) may cause allergic conjunctivitis.

Spectacle & Contact Lens History — Useful Questions

Systemic Conditions with Major Ocular Relevance

Key Systemic History Questions

• “Do you have any medical conditions I should know about?”
• “Have you been diagnosed with diabetes? If so, Type 1 or 2? How long ago? How is it controlled — diet, tablets, or insulin?”
• “Do you have high blood pressure? Is it being treated? What is your most recent reading?”
• “Have you ever been told you have high cholesterol or cardiovascular disease?”
• “Have you ever had a stroke or TIA?”
• “Do you have any autoimmune or inflammatory conditions — arthritis, lupus, thyroid disease, inflammatory bowel disease, psoriasis?”
• “Have you had any neurological conditions — MS, Parkinson's, epilepsy?”
• “Have you had any serious infections or are you immunocompromised?”
• “Have you had any cancer or chemotherapy?”

Eliciting a Medication History

Ask about all medications: prescription, over-the-counter, herbal, supplement, and topical. Many patients do not consider non-prescription items as “medications.” Specific prompting is required.

1. “Are you taking any prescribed medications at the moment — tablets, injections, patches, inhalers?”
2. “Are you using any eye drops — whether prescribed or over the counter?”
3. “Are you taking any vitamins, supplements, or herbal remedies?”
4. “Do you use any nasal sprays or skin creams regularly?” (Topical corticosteroids can raise IOP.)
5. “Have you had any steroid injections recently?”
6. “Are you on any blood thinners such as aspirin, warfarin, or newer agents like apixaban or rivaroxaban?”

Drugs with Significant Ocular Side Effects

Allergies

• Ask about all allergies: drug, topical, contact, environmental, food. Record the specific substance and the nature of the reaction (rash, anaphylaxis, intolerance).
• Local anaesthetic allergy: Relevant if GAT or other contact procedures are planned. Consider rebound tonometry (iCare) or NCT as alternatives.
• Fluorescein allergy (rare): Systemic fluorescein angiography carries more risk than topical fluorescein; document if reported. Topical fluorescein allergy is very uncommon but document if stated.
• Contact allergy: Nickel, thiomersal (formerly used in contact lens solutions), benzalkonium chloride (BAK — preservative in many topical drops) — relevant for contact lens wearers and patients on long-term topical medications.
• Eye drop preservative sensitivity: Many patients report “sensitivity” to drops without true allergy. BAK-preserved drops can cause significant ocular surface toxicity with long-term use. Consider preservative-free formulations for glaucoma patients on multiple drops.

A. Family History

Why Family History Matters in Eye Care

Many common and vision-threatening eye conditions have strong heritable components. Family history is a significant independent risk factor for several conditions and should be explicitly elicited — patients often do not volunteer this information unless asked directly.

Key Questions

• “Is there any history of eye disease in your family — parents, brothers, sisters, or children?”
• “Has anyone in your family been diagnosed with glaucoma or had blind spots in their vision?”
• “Has anyone in your family had macular degeneration or lost central vision as they got older?”
• “Is there any family history of blindness or significant visual loss?”
• “Do any close family members have diabetes or heart disease?”
• “Do any family members wear very strong glasses or have high short-sightedness?” (for myopia management)

B. Paediatric Patients

• History from carer and child: Obtain history primarily from the parent or carer, but also engage the child directly — even young children can describe symptoms in their own words. Always address the child, not just the accompanying adult.
• Birth and developmental history: Gestational age (prematurity → ROP risk), birth weight, birth complications, developmental milestones — particularly motor and language delay (associated with amblyopia and binocular vision problems).
• School performance: Difficulty reading? Sitting close to the board? Avoiding near tasks? Headaches after schoolwork? These are red flags for undetected refractive error, amblyopia, or convergence insufficiency.
• Strabismus: “Does your child's eye ever turn or look in a different direction?” “Did any family members have a lazy eye or squint as a child?”
• Myopia risk assessment: Time spent outdoors per day (<2 hours is a risk factor); screen time; parental myopia. Key for early myopia management intervention decisions.
• Safeguarding awareness: Non-accidental injury (NAI) can present with ocular findings. Be alert to inconsistent histories, unexplained periorbital bruising, retinal haemorrhages in infants. Follow local child safeguarding protocols if concerned.

C. Elderly Patients

• Falls risk: Visual impairment is a major risk factor for falls in older adults. Ask about recent falls, difficulty with steps or kerbs, and reduced confidence in low-light environments. Refer to falls prevention services where appropriate.
• Polypharmacy: Patients over 65 may be taking multiple medications with ocular side effects. A systematic medication review is particularly important in this age group. Ask about recent medication changes.
• Cognitive impairment: Patients with dementia may not reliably report symptoms or medication history. Involve the accompanying carer. Cognitive impairment itself can affect visual processing — rule out ocular causes before attributing visual complaints to cognition.
• Low vision and functional assessment: For patients with established visual impairment, assess functional impact: reading, face recognition, mobility, independence with daily tasks, emotional wellbeing. Refer to low vision services and community support organisations.
• GCA awareness: Any patient over 50 presenting with sudden visual loss, headache, jaw claudication, scalp tenderness, or raised inflammatory markers — suspect giant cell arteritis immediately. Do not defer — same-day referral and treatment.

D. Pregnant & Breastfeeding Patients

• Refractive changes: Fluid retention and hormonal changes during pregnancy can transiently alter corneal shape and refractive error. Advise against ordering new spectacles until after delivery and cessation of breastfeeding unless the change is significant.
• Pre-eclampsia: Can cause visual symptoms — flashing lights, blurred vision, diplopia. Any pregnant patient with these symptoms and raised blood pressure requires urgent obstetric review.
• Drug safety: Many topical ophthalmic agents are category C or D in pregnancy. Minimise topical anaesthetic use; avoid unnecessary dilation. If mydriatics must be used, nasolacrimal occlusion reduces systemic absorption.
• Contact lenses: Some patients notice contact lens intolerance during pregnancy due to corneal changes and dry eye. Reassure and consider temporary spectacle wear.
• Diabetic retinopathy: Pre-existing DR can worsen significantly during pregnancy. Ensure diabetic patients are in a pregnancy-specific diabetic eye screening pathway.

Essential Clinical Documentation

• Record contemporaneously: Document history findings at the time of the consultation, not retrospectively. Contemporaneous records are more accurate and carry greater medicolegal weight.
• Use the patient's own words for the chief complaint: Record the CC verbatim in quotation marks where possible — “blurry reading for 2 weeks” rather than “reduced near VA.” This preserves clinical accuracy and is medicolegally important.
• Negative findings matter: Explicitly document pertinent negatives — “No flashes, no floaters, no headache” is clinically meaningful if the patient later presents with these symptoms.
• Drug allergies must be prominently displayed: Document all allergies at the top of the record, flagged clearly. Incorrect or absent allergy documentation is a significant source of adverse events.
• Record driving advice: If you advise a patient they do not meet the legal driving standard, document this explicitly: “Advised patient that current VA does not meet the [DVLA Group 1 / Austroads / state] standard. Advised to cease driving until further assessment/correction.”
• GDPR / privacy compliance: In the UK, EU, Australia, and many other jurisdictions, patient records are subject to data protection legislation. Records must be kept securely, retained for the required period (typically 7–10 years for adults; longer for children), and provided to patients upon request.

Patient and Family Communication

• Use plain language: Avoid jargon unless the patient demonstrates clinical familiarity, and adjust vocabulary to health literacy.
• Confirm all concerns early: Ask whether there is anything else the patient wants addressed to avoid late-emerging concerns.
• Address ideas, concerns, and expectations: Explore what the patient thinks is happening, what worries them most, and what outcome they expect.
• Communicate legal advice clearly: Explain and document driving advice where visual standards are not met.
• Involve carers when needed: Especially for children, elderly patients, and patients with cognitive impairment or language barriers.