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History Form
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Exam Form
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Review of PMHx/FHx/allergies?
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Patient alert, mood normal, and oriented x 3?
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Reason for visit
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Chief Complaint
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Location
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Context
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Duration
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Severity
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Timing
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Modifiers
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Associated symptoms
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Hx/Medical Review
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PCP
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LPE
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Last ECP
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LEE
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Patient Medical Hx
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Medical History Notes
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Family Medical History
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Family Medical History Notes
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Patient Ocular History
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Ocular History Notes
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Family Ocular History
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Family Ocular History Notes
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Current meds
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Other meds
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Allergies
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Other Allergies
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Social History
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Smoker?
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Drinks alcohol?
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Uses unprescribed drugs?
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Exposure to STD's?
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Pre-testing
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Pre-Testing Documents
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Autorefraction OD sphere
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Autorefraction OD cyl
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Autorefraction OD axis
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Autorefraction OS sphere
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Autorefraction OS cyl
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Autorefraction OS axis
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PD
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Keratometry OD steep / flat @ axis
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Keratometry OS steep / flat @ axis
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Current glasses OD sphere
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Current glasses OD cyl
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Current glasses OD axis
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Glasses add OD
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Current glasses OS sphere
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Current glasses OS cyl
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Current glasses OS axis
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Glasses add OS
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Other Rx OD
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Other Rx OS
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NCT OD / OS
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Was Stereo Testing Normal?
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Stereo Testing Notes
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Was Color Vision Normal?
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Color Vision Notes
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VF Screening Normal OU?
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Was Visual Field Screening Normal OD?
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Visual Field Notes OD
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Was Visual Field Screening Normal OS?
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Visual Field Notes OS
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Entrance Tests
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Uncorrected VA
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Distance VA without correction OD
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Near VA without correction OD
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Distance VA without correction OS
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Near VA without correction OS
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Pinhole VA OD
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Pinhole VA OS
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Corrected VA
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Corrected VA measured through...
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Corrected Distance VA OD
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Corrected Near VA OD
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Corrected Distance VA OS
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Corrected Near VA OS
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Pinhole VA OD
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Pinhole VA OS
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PERRLA OU?
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Pupil Notes
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EOM's full and unrestricted OU?
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EOM Notes
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NPC
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NPC Break
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Cover Test Distance
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Amount of Distance Phoria/Tropia
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Cover Test Near
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Amount of Near Phoria/Tropia
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Additional IOP performed?
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IOP method
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IOP OD/OS
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CVF Performed?
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CVF Results
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Refraction/Phorometry Performed?
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Manifest Refraction OD sphere
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Manifest Refraction OD cyl
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Manifest Refraction OD axis
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Distance BCVA OD
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Manifest Refraction OS sphere
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Manifest Refraction OS cyl
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Manifest Refraction OS axis
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Distance BCVA OS
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Manifest Add OD
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Near BCVA OD
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Manifest Add OS
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Near BCVA OS
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Use Manifest as Final Rx?
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Final Rx different than manifest?
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Final Rx OD sphere
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Final Rx OD cyl
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Final Rx OD axis
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Final Add OD
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Final Rx OS sphere
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Final Rx OS cyl
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Final Rx OS axis
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Final Add OD
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Rx Notes OD
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Rx Notes OS
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Spec Type Recommended
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Enhancements Recommended
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Cycloplege Performed?
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Cycloplegic Refraction OD
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Cycloplegic VA OD
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Cycloplegic Refraction OS
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Cycloplegic VA OS
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Accommodation Testing?
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Near Testing Through...
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Accommodative Amps
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NRA
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PRA
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Accomodation Notes
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Dilation performed today
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Dilation Drops
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Dilation not performed
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Reason for not dilating
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All Anterior Segment Normal OU?
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Lids/Lashes Normal OU?
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Lids and Lashes OD
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Lids and Lashes OS
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Tear Film Normal OU?
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Tear Film OD
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Tear Film OS
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Corneas Normal OU?
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Cornea OD
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Cornea OS
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Conjunctivae Normal OU?
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Conjunctivae OD
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OD Conjunctiva Notes
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Conjunctivae OS
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OS Conjunctiva Notes
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Anterior Chambers Normal OU?
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Anterior Chamber OD
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Anterior Chamber OS
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Irises Normal OU?
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Iris OD
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Iris OS
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Lenses Clear OU?
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Lens OD
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Lens OS
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Anterior Seg Notes OD
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Anterior Seg Notes OS
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Anterior Seg OD
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Anterior Seg OS
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All Posterior Seg Normal OU?
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Fundus lenses used
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Optic Discs Normal OU?
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Optic Disc OD
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Optic Disc OS
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OD C/D ratio V / H
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C/D notes for OD
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OS C/D ratio V / H
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C/D notes for OS
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Retinal Vessels Normal OU?
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Retinal Vessels OD
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Retinal Vessels OS
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Maculae Normal OU?
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Macula OD
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Macula OS
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Vitreous Normal OU?
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Vitreous OD
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Vitreous OS
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Posterior Pole Normal OU?
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Posterior Pole OD
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Posterior Pole OS
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Periphery Normal OU?
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Periphery OD
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Periphery OS
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Posterior Seg Notes OD
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Posterior Seg Notes OS
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Posterior Seg OD
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Posterior Seg OS
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Contact Lens Exam Today?
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Current CL (or trial) wearer
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No CL's worn before
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Previous CL wearer
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Most recent CL type OD
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Most recent CL type OS
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BC / Diam OD
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CL power OD
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Distance VA w/ hab CL OD
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CL Add OD
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NVA w/ CL OD
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Over-refraction OD
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VA with OR OD
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Over-refraction OS
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VA with OR OS
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BC / Diam OS
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CL power OS
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Distance VA w/ hab CL OS
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CL Add OS
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NVA w/ CL OS
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Centration/Coverage OD
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Centration/Coverage OS
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MOB OD
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MOB OS
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CL Notes OD
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CL Notes OS
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New CL fit today?
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Lens type fit today OD (trial)
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Lens type fit today OS (trial)
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BC / Diam OD
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CL sphere OD
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CL cyl OD
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CL axis OD
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CL Add OD
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BC / Diam OS
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CL sphere OS
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CL cyl OS
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CL axis OS
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CL Add OS
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Centration/Coverage OD
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Centration/Coverage OS
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MOB OD
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MOB OS
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CL Notes OD
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CL Notes OS
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Distance VA w/ CL OD (trial)
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NVA w/ CL OD (trial)
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Distance VA w/ CL OS (trial)
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NVA w/ CL OS (trial)
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Plan for Trial Lens OD
• • •
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Plan for Trial Lens OS
• • •
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Miscellaneous Notes?
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Notes
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E-signature
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