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MHx/FHx/Meds/Allergies REVIEWED
Prescreen?
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
• • •
EOM
• • •
COVER TEST
• • •
CVF
• • •
SUBJECTIVE REFRACT
SUBJECTIVE REFRACTION OD
VA OD
SUBJECTIVE REFRACTION OS
VA OS
ADD (+)
NEAR VA OU
NRA(+)/PRA(-)
BINOCULAR BALANCED FINAL SRX
PHORIA DIST
PHORIA NEAR
WET/CYCLO
CYCLO VA
NPC
ANT SEG?
NEUROLOGIC
• • •
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
• • •
IOP (Icare) OD/OS
/
IOP (Goldmann) OD/OS
/
Anterior Segment OD
Anterior Segment OS
Post Seg?
Dilation Refusal SIG
LENS
• • •
DILATION
OPTIC NERVE
• • •
ONH Comments
C/D RATIO 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

H&P Physical Exam Medical Form

Optometrist

More detailed Comprehensive Eye Exam

There are 206 copies in use.
Published: May 24, 2012, 1:39 p.m.
Doctor: Dr. History Physical
Rating: +55   /

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