|
LEE:
/
|
|
|
Entering VA
• • •
|
|
|
DVcc OD:
• • •
|
DVcc OS:
• • •
|
|
DVsc OD:
• • •
|
DVsc OS:
• • •
|
|
NVcc OD:
• • •
|
NVcc OS:
• • •
|
|
NVsc OD:
• • •
|
NVsc OS:
• • •
|
|
Comments
|
|
|
Wearing Rx OD Sph:
• • •
|
|
|
Wearing Rx OD Cyl:
• • •
|
|
|
Wearing Rx OD Axis:
• • •
|
OD Exact Axis
|
|
Wearing Rx OS Sph:
• • •
|
|
|
Wearing Rx OS Cyl:
• • •
|
|
|
Wearing Rx OS Axis:
• • •
|
OS Exact Axis
|
|
Wearing Add
• • •
|
|
|
Ret/AR OD Sph
• • •
|
|
|
Ret/AR OD Cyl
• • •
|
|
|
Ret/AR OD Axis
• • •
|
|
|
Ret/AR OS Sph
• • •
|
|
|
Ret/AR OS Cyl
• • •
|
|
|
Ret/AR OS Axis
• • •
|
|
|
Keratometry OD
/
|
Keratometry OD Axis
• • •
|
|
Keratometry OS
/
|
Keratometry OS Axis
• • •
|
|
Comments
|
|
|
Manifest Rx Same as Wearing Rx
|
|
|
MR OD Sph:
• • •
|
|
|
MR OD Cyl:
• • •
|
|
|
MR OD Axis:
• • •
|
OD Exact Axis
|
|
MR OD VA
• • •
|
PinHole OD
|
|
MR OS Sph:
• • •
|
|
|
MR OS Cyl:
• • •
|
|
|
MR OS Axis:
• • •
|
OS Exact Axis
|
|
MR OS VA:
• • •
|
PinHole OS
|
|
ADD OD:
• • •
|
Near OD VA:
• • •
|
|
ADD OS:
• • •
|
Near OS VA:
• • •
|
|
FCC:
|
Pupilary Distance
/
|
|
Comments
|
|
|
Final Rx same as Manifest Refraction
|
|
|
Final RX
|
|
|
Final Spec Rx OD Sph:
• • •
|
|
|
Final Spec Rx OD Cyl:
• • •
|
|
|
Final Spec Rx OD Axis:
• • •
|
OD Exact Axis
|
|
Final Spec Rx OS Sph:
• • •
|
|
|
Final Spec Rx OS Cyl:
• • •
|
|
|
Final Spec Rx OS Axis:
• • •
|
OD Exact Axis
|
|
Intermediate ADD:
• • •
|
|
|
Near ADD
• • •
|
|
|
Comments
|
|
|
Additional Testing
|
|
|
Ishihara OD:
|
Ishihara OS:
|
|
Stereo OD
|
Stereo OS
|
|
EOMS FULL SMOOTH OU:
|
PERRL OD/OS:
|
|
CVF FTFC OD / OS:
|
|
|
Comments
|
|
|
Slit Lamp Examination
|
|
|
IOP OD:
• • •
|
IOP OS:
• • •
|
|
Gonioscopy OS
• • •
|
Gonioscopy OD
• • •
|
|
Instilled Dilation Drops Given
|
Dilation Deferred
|
|
Dilating Drops Used:
• • •
|
SLE:
|
|
|
DFE:
|
|
Comments:
|
|
|
Assessment & Plan
|
|
|
A1:
|
P1:
|
|
A2
|
P2.
|
|
A3.
|
P3.
|
|
A4.
|
P4.
|
|
RTO
|
|
