|
Habitual Rx:
|
Habitual Rx:
|
|
Visual acuity with habitual RX:
• • •
|
Visual acuity with habitual Rx:
• • •
|
|
Autorefract OD
|
Autorefraction OS
|
|
Uncorrected Visual Acuity OD
|
Uncorrected Visual Acuity OS
|
|
Dilated OD
|
Dilated OS
|
|
Afferent Pupillary Defect OD
|
Afferent Pupillary Defect OS
|
|
Color Vision WNL?
|
Stereopsis
|
|
Pupils PERRLA?
|
Cover test
• • •
|
|
CVF OD
|
CVF OS
|
|
EOM motilities
|
Psych: Mood/Affect
|
|
Head/Face normal limits?
|
Neuro: Oriented person/place
|
|
SUBJECTIVE REFRACTION
|
|
|
OD Subj Refraction:
|
OS Subj Refraction:
|
|
Visual acuity:
• • •
|
Visual acuity
• • •
|
|
ADD POWER
|
ADD POWER
|
|
Near Acuity
|
Near Acuity
|
|
ANTERIOR SEGMENT
|
|
|
Lids OD WNL
|
Lid OD
• • •
|
|
Lids OS WNL
|
Lid OS
• • •
|
|
Conjunctiva/Sclera OD WNL?
|
Conjunctiva/Sclera OD
• • •
|
|
Conjunctiva/Sclera OS WNL?
|
Conjunctiva/Sclera OS
• • •
|
|
Cornea OD WNL?
|
Cornea OD
• • •
|
|
Cornea OS WNL?
|
Cornea OS
• • •
|
|
Ant chamber/Iris OD WNL?
|
|
|
Ant chamber/Iris OS WNL?
|
C/D ratio OS
|
|
Lens OD Clear?
|
Lens OD
• • •
|
|
Lens OS Clear?
|
Lens OS
• • •
|
|
|
|
|
POSTERIOR SEGMENT
|
OD Vessels
|
|
|
|
|
Vitreous OD WNL?
|
OS Vessels
|
|
Vitreous OS WNL?
|
comments
|
|
Optic Nerve OD WNL?
|
Optic Nerve OD
• • •
|
|
Optic Nerve OS WNL?
|
Optic Nerve OS
• • •
|
|
|
|
|
C/D ratio OD:
|
|
|
Macula OD WNL?
|
Macula OD
• • •
|
|
Macula OS WNL?
|
Macula OS
• • •
|
|
Vessels OD WNL?
|
Vessels OD
• • •
|
|
Vessels OS WNL?
|
Vessels OS
• • •
|
|
Periphery OD WNL?
|
Periphery OD
• • •
|
|
Periphery OS WNL?
|
Periphery OS
• • •
|
|
|
|
|
|
|
|
IOP OD
|
IOP OS
|
