|
Autorefract/Retinoscopy OD
|
Autorefract/Retinoscopy OS
|
|
Keratometry OD
|
Keratometry OS
|
|
Color Vision WNL?
|
Stereopsis
|
|
IOP OD
|
IOP OS
|
|
Habitual Rx and acuity OD:
|
Habitual Rx and acuity OS:
|
|
Uncorrected Visual Acuity OD
|
Uncorrected Visual Acuity OS
|
|
Pinhole acuity OD
|
Pinhole acuity OS
|
|
Pupils PERRLA?
|
comments
|
|
CVF OD
|
CVF OS
|
|
Automated perimetry OD:
|
Automated perimetry OS:
|
|
EOM motilities
|
Cover Test
|
|
NPC
|
Psych: Mood/Affect
|
|
Head/Face normal limits?
|
Neuro: Oriented (person/place/t
|
|
Dilated
|
|
|
SUBJECTIVE REFRACTION
|
|
|
OD Subj Refraction and acuity
|
OS Subj Refraction and acuity
|
|
ADD POWER
|
Near Acuity
|
|
ANTERIOR SEGMENT
|
|
|
Lid OD WNL
|
comments
|
|
Lid OS WNL
|
comments
|
|
Conjunctiva/Sclera OD WNL?
|
comments
|
|
Conjunctiva/Sclera OS WNL?
|
comments
|
|
Cornea OD WNL?
|
comments
|
|
Cornea OS WNL?
|
comments
|
|
Ant chamber/Iris OD WNL?
|
comments
|
|
Ant chamber/Iris OS WNL?
|
comments
|
|
Lens OD Clear?
|
comments
|
|
Lens OS Clear?
|
comments
|
|
Anterior Segment OD
|
Anterior Segment OS
|
|
POSTERIOR SEGMENT
|
|
|
Vitreous OD WNL?
|
comments
|
|
Vitreous OS WNL?
|
comments
|
|
Optic Nerve OD WNL?
|
OD optic nerve comments
|
|
Optic Nerve OS WNL?
|
OS optic nerve comments
|
|
C/D ratio OD:
|
C/D ratio OS
|
|
Macula OD WNL?
|
comments
|
|
Macula OS WNL?
|
comments
|
|
Vessels OD WNL?
|
OD Vessels
|
|
Vessels OS WNL?
|
OS Vessels
|
|
Periphery OD WNL?
|
comments
|
|
Periphery OS WNL?
|
comments
|
|
Retina OD
|
Retina OS
|
