|
New VA only
|
Est. VA only
|
|
New VA & SV Spex
|
Est. VA & SV Spex
|
|
New VA & BF Spex
|
Est. VA & BF Spex
|
|
New VA, Fit, & CL's
|
Est VA, Fit, & CL's
|
|
IOP OD
|
IOP OS
|
|
SC VA OD
|
SC VA OS
|
|
SC VA OU Dist
|
SC VA OU Near
|
|
PREVIOUS GLASSES Rx OD
|
PREVIOUS GLASSES RX OS
|
|
Add
|
|
|
Previous CL Rx OD
|
Previous CL Rx OS
|
|
Previous CL Brand OD
|
Previous CL Brand OS
|
|
K-value OD
|
K-value OS
|
|
CC VA OD
|
CC VA OS
|
|
CC VA OU Dist
|
CC VA OU Near
|
|
Type of Contact Lens Fitting
• • •
|
|
|
CL Rx OD
|
CL Rx OS
|
|
Type of Contact Lens for OD
|
Type of Contact Lens for OS
|
|
Unlisted Type of Contacts
|
Unlisted Type of Contacts
|
|
Retinoscopy OD
|
Retinoscopy OS
|
|
Subjective OD
|
Subjective OS
|
|
CC Visual Acuity OD
|
CC Visual Acuity OS
|
|
Spex Final Rx OD
|
Spex Final Rx OS
|
|
Final Add
|
Near BVA
|
|
COLOR VISION ISHIHARA
• • •
|
|
|
Afferent Pupillary Defect OD
|
Afferent Pupillary Defect OS
|
|
Confrontation Visual Field OD
• • •
|
Confrontation Visual Field OS
• • •
|
|
EOMs
|
|
|
Lid OD WNL
|
Lid OS WNL
|
|
Lid OD
|
Lid OS
|
|
Conjunctiva/Sclera OD WNL?
|
Conjunctiva/Sclera OS WNL?
|
|
Conjunctiva/Sclera OD
• • •
|
Conjunctiva/Sclera OS
• • •
|
|
Cornea OD WNL?
|
Cornea OS WNL?
|
|
Cornea OD
• • •
|
Cornea OS
• • •
|
|
Iris OD WNL?
|
Iris OS WNL?
|
|
Iris OD
• • •
|
Iris OS
• • •
|
|
Lens OD Clear?
|
Lens OS Clear?
|
|
Lens OD
|
Lens OS
|
|
Anterior Segment OD
|
Anterior Segment OS
|
|
Dilated OD
|
Dilated OS
|
|
DILATION DROPS
• • •
|
DILATION DROPS
• • •
|
|
Vitreous OD WNL?
|
Vitreous OS WNL?
|
|
Cup to Disc Ratio OD
|
Cup to Disc Ratio OS
|
|
Optic Nerve OD WNL?
|
Optic Nerve OS WNL?
|
|
Macula OD WNL?
|
Macula OS WNL?
|
|
Macula OD
• • •
|
Macula OS
• • •
|
|
Vessels OD WNL?
|
Vessels OS WNL?
|
|
Vessels OD
|
Vessels OS
|
|
Periphery OD WNL?
|
Periphery OS WNL?
|
|
Periphery OD
• • •
|
Periphery OS
• • •
|
|
Retina OD
|
Retina OS
|
|
Final Rx OD 2 (Spex)
|
Final Rx OS 2 (Spex)
|
|
Final Add 2
|
Notes
|
