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MHx/FHx/Meds/Allergies REVIEWED
OBJECTIVE
VAsc @ Distance OD
VAsc @ Distance OS
VAsc @ Near OD
VAsc @ Near OS
VAcc @ Distance OD
VAcc @ Distance OS
Type of Correction for VAcc
LENSOMETRY OD / OS
AUTOREFRACTION OD / OS
AUTOKERATOMETRY OD / OS
COLOR VISION (Ishihara)
STEREOVISION
• • •
WELLNESS VF SCREENING
• • •
PUPILS
• • •
COVER TEST
• • •
EOM
• • •
SUBJECTIVE REFRACTION OD
CVF
• • •
SUBJECTIVE REFRACTION OS
VA OD
ADD (+)
VA OS
NRA(+)/PRA(-)
NEAR VA OU
PHORIA DIST
BINOCULAR BALANCED FINAL SRX
WET/CYCLO
PHORIA NEAR
NPC
CYCLO VA
ANTERIOR SEG
PRE-AURICULAR NODE; Palpable?
NEUROLOGIC
• • •
EYELIDS/LASHES
• • •
OCULAR ADNEXA
• • •
CONJUNCTIVA
• • •
SCLERA/EPISCLERA
• • •
ANTERIOR CHAMBER
• • •
CORNEA
• • •
IRIS
• • •
ANGLE ESTIMATE
• • •
IOP (Icare) OD/OS
IOP (Goldmann) OD/OS
Anterior Segment OD
Anterior Segment OS
POSTERIOR SEG
DILATION
LENS
• • •
VITREOUS
• • •
C/D RATIO OD, OS
OPTIC NERVE
• • •
FOVEAL REFLEX OU?
MACULA
• • •
POSTERIOR POLE
• • •
VASCULATURE
• • •
PERIPHERY
• • •
Retina OD
Retina OS
ASSESSMENT
• • •
PLAN (needs work)
• • •

H&P Physical Exam Medical Form

Optometrist

Eye Exam template ( I substitute it for the H&P physical, then use the H&P list for exam flow).

There are 44 copies in use.
Published: May 22, 2012, 5:32 p.m.
Doctor: Dr. History Physical
Rating: +5   /

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