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Orientation
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Vision Exam
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VA Test Modality
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Correction?
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Va OD
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Va OD 2
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Va OS
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Va OS 2
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Pinhole OD
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Pinhole OS
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Pupils
• • •
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Pupils Comments
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EOM OD
• • •
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EOM OS
• • •
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Cover/Uncover
• • •
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Cover/Uncover Comment
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Nystagmus
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CVF OD
• • •
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CVF OS
• • •
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CVF Ptosis
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Color Plates OD
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Color Plates OS
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Red Desat OD
• • •
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Red Desat OS
• • •
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IOP OD
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IOP OS
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IOP FT
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NML CN V, VII, VIII
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Adnexa
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Right Orbit
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Left Orbit
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Hertel Base
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Hertel OD
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Hertel OS
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Right Brow
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Left Brow
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RUL
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LUL
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RLL
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LLL
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Lagophthalmos OD
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Lagophthalmos OS
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Belll's Phenomenon OD
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Bell's Phenomenon OS
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MRD1 OD
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MRD1 OS
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LF OD
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LF OS
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Phenylephrine OD
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Phenylephrine OS
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Enhancement OD
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Enhancement OS
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Ice Test
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Face
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Sup Scleral Show OD
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Sup Scleral Show OS
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Inf Scleral Show OD
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Inf Scleral Show OS
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Snap Back OD
• • •
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Snap Back OS
• • •
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Lacrimal
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Probing and Intubation
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P/I OD
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P/I OS
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RUL Punctum
• • •
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LUL Punctum
• • •
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RLL Punctum
• • •
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LLL Punctum
• • •
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RUL Canaliculus
• • •
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LUL Canaliculus
• • •
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RLL Canaliculus
• • •
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LLL Canaliculus
• • •
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Nasolacrimal Duct OD
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Nasolacrimal Duct OS
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Tear meniscus OD
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Tear meniscus OS
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Lacrimal Notes
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Anterior Segment
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Anterior Segment Normal
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Conjunctiva/Sclera Normal OS
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Conjunctiva/Sclera Normal OD
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Conjunctiva/Sclera OS
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Conjunctiva/Sclera OD
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Cornea Normal OS
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Cornea Normal OD
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Cornea OS
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Cornea OD
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Schirmer OS
• • •
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Schirmer OD
• • •
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AC OS Normal
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AC OD Normal
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AC OS
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AC OD
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Iris Normal OS
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Iris Normal OD
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Iris OS
• • •
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Iris OD
• • •
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Lens Normal OS
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Lens Normal OD
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Lens OS
• • •
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Lens OD
• • •
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Fundus
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Dilation
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DFE Normal
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Vitreous Normal OD
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Vitreous Normal OS
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Vitreous OD
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Vitreous OS
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ON nml OD
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ON nml OS
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C/D OD
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C/D OS
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Macula nml OD
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Macula nml OS
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Macula OD
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Macula OS
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Vessels nml OD
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Vessels nml OS
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Vessels OD
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Vessels OS
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Periphery nml OD
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Periphery nml OS
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Periphery OD
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Periphery OS
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Ancillary Tests
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Visual Field OD
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Visual Field OS
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Imaging
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Labs
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Photos
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