|
When was the last time you were seen?
|
|
|
MHx/FHx/Meds/Allergies and HPI REVIEWED
|
Contact Lens Fit today?
|
|
What kind of CL are you currently wearing?
• • •
|
CL RX
|
|
Do you wish to be dilated today?
|
Dilation Refusal SIG
|
|
IOPS - Unable to Test
|
IOP (Icare) OD/OS
/
|
|
|
|
|
PUPILS
• • •
|
EOM
• • •
|
|
COVER TEST
• • •
|
CVF
• • •
|
|
NPC
|
Additional Testing
|
|
Autorefraction
|
Additional Testing
|
|
Type of Correction for VAcc
|
|
|
VAcc @ Distance OD
|
VA cc @ Distance OS
|
|
VAsc @ Distance OD
|
VAsc @ Distance OS
|
|
VA with correction?
|
|
|
VA @ Near OD
|
VA @ Near OS
|
|
WELLNESS VF SCREENING
• • •
|
Additional Comments
|
|
|
|
|
Children Testing
|
|
|
COLOR VISION (Ishihara)
|
STEREOVISION
• • •
|
|
|
|
|
Order:
|
|
|
• • •
|
|
|
|
|
|
Doctor Section
|
|
|
SUBJECTIVE REFRACT
|
Va 20/20 OD 20/20 OS 20/20 OU
|
|
SUBJECTIVE REFRACTION OD
|
VA OD
|
|
SUBJECTIVE REFRACTION OS
|
VA OS
|
|
ADD (+)
|
NEAR VA OU
|
|
BINOCULAR BALANCED FINAL SRX
|
SPECIAL INSTRUCTIONS
|
|
|
|
|
NRA(+)/PRA(-)
|
|
|
PHORIA DIST
|
PHORIA NEAR
|
|
WET/CYCLO
|
CYCLO VA
|
|
Reading only Rx OD
|
Reading only Rx OS
|
|
|
|
|
ANT SEG?
|
Anterior Segment Normal
|
|
OCULAR ADNEXA
• • •
|
OA Comments:
|
|
PRE-AURICULAR NODE; Palpable?
|
PA Comments:
|
|
EYELIDS/LASHES
• • •
|
Lids/Lashes Comments
|
|
SCLERA/EPISCLERA
• • •
|
S/E Comments
|
|
CONJUNCTIVA
• • •
|
Conj Comments
|
|
CORNEA
• • •
|
Cornea Comments
|
|
IRIS
• • •
|
Iris Comments
|
|
ANTERIOR CHAMBER
• • •
|
AC Comments
|
|
|
|
|
ANGLE ESTIMATE
• • •
|
|
|
Anterior Segment OD
|
Anterior Segment OS
|
|
|
|
|
Dilation?W
|
DILATION
|
|
Post Seg?
|
Posterior Segment Normal
|
|
CD Ratio OD
/
|
CD RATIO OS
/
|
|
C/D .3 /.3 OD .3/.3 OS
|
BIO/ DIRECT/ 90/ 78
• • •
|
|
LENS
• • •
|
ONH Comments
|
|
OPTIC NERVE
• • •
|
IOP (Goldmann) OD/OS
/
|
|
MACULA
• • •
|
Macula Comments:
|
|
FOVEAL REFLEX OU?
|
|
|
VITREOUS
• • •
|
Vitreous Comments
|
|
POSTERIOR POLE
• • •
|
Post Pole Comments
|
|
VASCULATURE
• • •
|
Vasculature Comments
|
|
PERIPHERY
• • •
|
Periphery Comments
|
|
Retina OD
|
Retina OS
|
|
No Diabetic Changes Found
|
|
|
|
|
|
Doctor Signature
|
|
|
Rendering Doctor
• • •
|
|
