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Doctor Eye Exam
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Name and DOB
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Today
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Chief Complaint and Meds
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Vision Test
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Eye Pressures
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Current Glasses RX
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OD
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ADD
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OS
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ADD
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Final Glasses RX
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OD
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ADD
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OS
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ADD
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Makes Glasses Available for Optical
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Contact Lenses
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Contact Lens Fitting Data
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OD
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ADD
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OS
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ADD
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Final CTL RX
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OD
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ADD
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OS
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ADD
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Make CTL Available for Optical
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Medical Evalutaion
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Color Charted?
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Stereo Charted?
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Are the following measurements within normal parameters?
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CVF OD
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CVF OS
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EOMs
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Primary Gaze OD
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Primary Gaze OS
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Conjunctiva
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Bulbar OD
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Bulbar OS
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Palpebral OD
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Palpebral OS
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Adnexa/Lids
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Orbit OD
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Orbit OS
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Lacrimal Gland OD
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Lacrimal Gland OS
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Lacrimal Drainage OD
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Lacrimal Drainage OS
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Preauricular Lymphnodes OD
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Preauricular Lymphnodes OS
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Lids OD
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Lids OS
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Pupils & Iris
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Shape OD
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Shape OS
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Direct & Consensual Reaction OD
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Direct & Consensual Reaction OD
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Size OD
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Size OD
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Cornea
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Epithelium OD
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Epithelium OS
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Stroma OD
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Stroma OS
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Endothelium OD
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Endothelium OD
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Tear Film OD
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Tear Film OD
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Ant Chamber
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Depth OD
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Depth OS
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Clarity OD
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Clarity OD
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Lens
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Clarity OD
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Clarity OS
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Ant & Post Cap OD
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Ant & Post Cap OS
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Cortex OD
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Cortex OS
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Nucleus OD
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Nucleus OS
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Fundus/Dilate
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Dilated?
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Optic DIsk Size OD
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Optic DIsk Size OS
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C/D Ratio OD
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C/D Ratio OS
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Appearance OD
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Appearance OS
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Nerve Fiber Layer OD
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Nerve Fiber Layer OS
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Retina
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Macula OD
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Macula OS
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Vessels OD
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Vessels OS
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Periphery OD
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Periphery OS
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Mental Status (PPT)
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Mood/Affect
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Drawing(s)
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Free Draw 1
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Free Draw 2
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Free Draw 3
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Diagnosis and Assessment
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Diagnosis
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Diagnosis
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Diagnosis
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Diagnosis
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Diagnosis
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Diagnosis
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CPT Codes and Procedures
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CPT Code/Procedure
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CPT Code/Procedure
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CPT Code/Procedure
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CPT Code/Procedure
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CPT Code/Procedure
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CPT Code/Procedure
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CPT Code/Procedure
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CPT Code/Procedure
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Plan
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New Short Text Field
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New Short Text Field
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New Short Text Field
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New Short Text Field
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