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Interpreter Refused
|
|
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Patient History Form
|
Patient Exam Form
|
|
Pretesting Documents
|
VF Documents
|
|
Miscellaneous Forms (DMV, Referrals)
|
Miscellaneous Forms (DMV, Referrals)
|
|
Chief Complaint-reason for visit
• • •
|
Chief Complaint Comments
|
|
MHx/FHx/Meds/Allergies REVIEWED
|
NEUROLOGIC
• • •
|
|
Systemic Significance
• • •
|
Dilation? Y/N (If NO, ensure signature of refusal)
|
|
PRE-TESTS
|
|
|
NCT OD
|
NCT OS
|
|
NCT TIME
|
AUTOKERATOMETRY OD / OS
|
|
WELLNESS VF SCREENING
• • •
|
VISUAL FIELD COMMENT
|
|
VISION EXAMINATION
|
|
|
VAsc @ Distance OD
|
VA sc @ Distance OS
|
|
VAsc @ Near OD
|
VAsc @ Near OS
|
|
VAsc @ Distance OU
|
|
|
VAcc @ Distance OD
|
VAcc @ Distance OS
|
|
Type of Correction for VAcc
|
|
|
Current RX OD
|
Cyl
|
|
Axis
|
ADD (+)
|
|
Current RX OS
|
Cyl
|
|
Axis
|
ADD (+)
|
|
Entering Spectacle Rx OD
|
Entering Spectacle RX OS
|
|
Entering CL Rx OD
|
Entering CL Rx OS
|
|
REFRACTION:
|
PD:
|
|
Autorefraction OD
|
Autorefraction OS
|
|
Autorefract OD:::::::Subjective RX OD
|
Cyl
|
|
Axis
|
BCVA OD
|
|
Autorefract OS:::::::Subjective RX OS
|
Cyl
|
|
Axis
|
BCVA OS
|
|
ADD (+)
|
NEAR VA OD
|
|
NEAR VA OS
|
NEAR VA OU
|
|
BINOCULAR BALANCED FINAL SRX
|
Trial Frame
|
|
FINAL RX OD
|
FINAL RX OS
|
|
RX comments:
|
NRA(+)/PRA(-)
|
|
PHORIA DIST
|
PHORIA NEAR
|
|
CYCLO VA
|
WET/CYCLO
|
|
ENTRANCE TESTING
|
|
|
Entrance Testing All Normal
|
ENTRANCE TESTING
• • •
|
|
COVER TEST
• • •
|
CVF
• • •
|
|
PUPILS
• • •
|
NPC
|
|
EOM
• • •
|
STEREOVISION
• • •
|
|
COLOR VISION (Ishihara)
|
Comments
|
|
|
Blood Pressure
/
|
|
EYE HEALTH EXAM
|
ANT SEG ALL Normal OU
|
|
ANT SEG NORMAL OU
• • •
|
Anterior Segment Comments
|
|
OCULAR ADNEXA
• • •
|
OA Comments:
|
|
EYELIDS/LASHES
• • •
|
Lids/Lashes Comments
|
|
SCLERA/EPISCLERA
• • •
|
S/E Comments
|
|
CONJUNCTIVA
• • •
|
Conj Comments
|
|
CORNEA
• • •
|
Cornea Comments
|
|
IRIS
• • •
|
Iris Comments
|
|
ANTERIOR CHAMBER
• • •
|
AC Comments
|
|
Anterior Segment OD
|
Anterior Segment OS
|
|
Tonometry Method OU
|
IOP OD/OS
/
|
|
ANGLE ESTIMATE
• • •
|
Dilation Refusal SIG
|
|
DILATION
|
DPA TIME
|
|
Post Seg All Normal
|
|
|
Post Segment All Normal
• • •
|
Posterior Segment Comments
|
|
LENS
• • •
|
Lens commments
|
|
OPTIC NERVE
• • •
|
ONH Comments
|
|
MACULA
• • •
|
Macula Comments:
|
|
FOVEAL REFLEX OU?
|
|
|
VITREOUS
• • •
|
Vitreous Comments
|
|
VASCULATURE
• • •
|
Vasculature Comments
|
|
POSTERIOR POLE
• • •
|
Post Pole Comments
|
|
PERIPHERY
• • •
|
Periphery Comments
|
|
Cup to Disc Ratio OD
|
Cup to Disc Ratio OS
|
|
Retina OD
|
Retina OS
|
|
Assessment
• • •
|
PATIENT EDUCATION
• • •
|
|
Comments
|
Electronic Signature
• • •
|
|
|
|
|
CONTACT LENS EXAM
|
|
|
Contact Lens Exam
|
CL Comments
|
|
Brand
|
Power OD
|
|
Cyl
|
Axis
|
|
ADD (+)
|
Over Refraction OD
|
|
CL Fit Evaluation / Comments OD
• • •
|
BCVA with CL OD
|
|
Brand
|
Power OS
|
|
Cyl
|
Axis
|
|
ADD (+)
|
Over Refraction OS
|
|
CL Fit Evaluation/ Comments OS
• • •
|
BCVA with CL OS
|
|
Rewetting Drops (if needed)
|
Replacement Frequency
|
|
CL Solution
• • •
|
Assessment/Plan
• • •
|
|
Misc. Documents
|
CL Comments
|
