Papilledema Examination Form
Document key findings and clinical assessment for papilledema evaluation.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Examination Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Referring Provider
Presenting Symptoms
*
Blurred vision
Transient visual obscurations
Double vision
Headache
Nausea/Vomiting
Other
Duration of Symptoms (in days)
Visual Acuity (best corrected)
Fundoscopic Findings
*
Disc swelling
Hemorrhages
Cotton wool spots
Venous congestion
Normal
Other
Associated Features
Headache
Nausea
Vomiting
Diplopia
Tinnitus
Other
Clinician Assessment and Plan
*
Submit
Should be Empty: