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MHx/FHx/Meds/Allergies REVIEWED
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Prescreen?
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Type of Correction for VAcc
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VAcc @ Distance OD
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VAcc @ Distance OS
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WELLNESS VF SCREENING
• • •
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COLOR VISION (Ishihara)
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STEREOVISION
• • •
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VAsc @ Distance OD
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VAsc @ Distance OS
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VAsc @ Near OD
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VAsc @ Near OS
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AUTOREFRACTION OD, OS
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AUTOKERATOMETRY OD, OS
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LENSOMETRY OD, OS
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Previous SRx
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SUBJECTIVE REFRACT
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SUBJECTIVE REFRACTION OD
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VA OD
• • •
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SUBJECTIVE REFRACTION OS
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VA OS
• • •
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VA OU
• • •
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ADD (+)
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NEAR VA OU
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BINOCULAR BALANCED FINAL SRX
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NRA(+)/PRA(-)
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PHORIA DIST
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PHORIA NEAR
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Near Vergence BI (Break/Recovery)
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Near Vergence BO (Break/Recovery)
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NPC
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Maddox Rod H/V
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WET/CYCLO
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CYCLO VA
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Final SRx (not subjective)
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ANT SEG?
|
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PUPILS
• • •
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CVF
• • •
|
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COVER TEST
• • •
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EOM
• • •
|
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Comments
|
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OCULAR ADNEXA
• • •
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OA Comments:
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NEUROLOGIC
• • •
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PRE-AURICULAR NODE; Palpable?
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PA Comments:
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EYELIDS/LASHES
• • •
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Lids/Lashes Comments
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SCLERA/EPISCLERA
• • •
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S/E Comments
|
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CONJUNCTIVA
• • •
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Conj Comments
|
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CORNEA
• • •
|
Cornea Comments
|
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IRIS
• • •
|
Iris Comments
|
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ANTERIOR CHAMBER
• • •
|
AC Comments
|
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ANGLE ESTIMATE
• • •
|
|
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IOP (iCare) OD/OS
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IOP (Goldmann) OD/OS
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Anterior Segment OU
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BP, Pulse
|
|
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Post Seg?
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DFE Consent/Refusal
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DILATION
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LENS
• • •
|
Lens Comments
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OPTIC NERVE
• • •
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ONH Comments
|
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C/D RATIO OD/OS
|
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MACULA
• • •
|
Macula Comments:
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FOVEAL REFLEX OU (=no edema)?
|
|
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VITREOUS
• • •
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Vitreous Comments
|
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POSTERIOR POLE
• • •
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Post Pole Comments
|
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VASCULATURE
• • •
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Vasculature Comments
|
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PERIPHERY
• • •
|
Periphery Comments
|
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Posterior Segment OU
|
|
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Diabetic Retinopathy
• • •
|
AMD Level
• • •
|
