Eye, Ear, Nose & Throat Exam Patient:_______________________________________________

Check normal, circle & describe abnormal

Date: __________________ Date of birth: _______________ M/F
CC & significant history: ____________________________________________________ _____________________________________________________
__________________________________________________________________________
Temp: __________, Pulse: _______, Resp: _________, BP: L: _____/_____, R: _____/_____

Ophthalmic exam Right Left

Eye:: □ WNL □ Red reflex
□ Visual acuity: L: _______/_______ R: _______/_______
□ Optic cup & disc
□ corrected, □ uncorrected
□ Disc margins well defined
External inspection
□ Cup:disc ratio (1:2)
□ Size, shape symmetry: ____________________________
□ buldging □ cupping
□ Lids, lashes: ____________________________________
□ Trace blood vessels
□ Conjunctiva (pallor):: ______________________________
□ Macula
□ Iris, sclera, cornea:: _______________________________
□ Anterior chamber
□ Palpation: ______________________________________
_________________________________________
Examination
_________________________________________
□ Ocular movements: _______________________________
________________________________________
□ Visual fields: ____________________________________
□ PERRLA:: _______________________________________
□ Corneal reflex:: ___________________________________
_____________________________________________________________
□ Cover/uncover test: _____________________________
______________________________________________ _____________________________________________________________
_______________________________________________ _____________________________________________________________

Ear:: □ WNL Otoscopic exam

□ Auditory canal Left Right
□ Uncorrected, □ hearing aid
□ Tympanic membrane
External inspection
□ Irritation
□ Size, shape symmetry: ______________________________
□ Scarring
□ Position & alignment of head:: _________________________
□ Perforation
□ Skin condition (color, lumps, lesions):: ___________________
□ Cone of light
□ Auricular & tragus movement:: _________________________
□ Red reflex
□ External auditory meatus: ____________________________
□ Fluid level: _______________________
□ swelling, □ redness, □ discharge, □ cerumen
□ Discharge: _______________________
Examination
Pneumatic otoscopy
□ Watch test: L > = < R ________________________________
□ Brisk movement
□ Weber: =, lateralize L/R ______________________________
□ Slow/absent movement
□ Rinne:: AC > = < BC ________________________________
________________________________________
□ Vestibular function:: _________________________________
________________________________________
□ Swivel chair test:
test: _______________________________

Nose:: □ WNL Throat:: □ WNL

External inspection □ Size, shape symmetry: ___________________
□ Size, shape symmetry: _________________________________________ ________________________________________
□ Skin condition : _______________________________________________ ________________________________________
□ Deviated septum:: ______________________________________________ □ Lips: _________________________________
□ Congestion:: __________________________________________________ □ Mucos
Mucosaa
Rhinoscopic examination □ Buccal: _____________________________
□ Color: _______________________________________________________ □ Labial : _____________________________
□ Discharge: ___________________________________________________ □ Teeth: ________________________________
□ Ployps:: ______________________________________________________ ________________________________________
Sinus examination ________________________________________
□ Percussion:: __________________________________________________ □ Tonsils: _______________________________
□ Transillumination: ______________________________________________ ________________________________________
_____________________________________________________________ □ 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, Signature: Date:
not for resale or redistribution. www.prohealthsys.com ©2005 by Professional Health Systems Inc. All rights reserved. “Dedicated to Clinical Excellence.”