|
CL CC:
|
|
|
Over Contact Lens Rating
|
CL Interested
• • •
|
|
Wearing Contacts
• • •
|
Base Curve
• • •
|
|
RGP Fitting
|
Material
• • •
|
|
OD DIA:
|
OS DIA
|
|
OD Base Curve
|
OS Base Curve
|
|
OD Sph
• • •
|
|
|
OD Cyl
• • •
|
|
|
OD Axis
• • •
|
VA Distance OD
• • •
|
|
OS Sph
• • •
|
|
|
OS Cyl
• • •
|
|
|
OS Axis
• • •
|
VA Distance OS
• • •
|
|
OD Add
• • •
|
Near Visual Acuity
• • •
|
|
OS Add
• • •
|
Near Visual Acuity
• • •
|
|
Dominant
|
|
|
Comments
|
|
|
Fitting
|
|
|
Over Refraction OD:
|
VA Distance OD
• • •
|
|
Over Refraction OS:
|
VA Distance OS
• • •
|
|
Placement
• • •
|
Comfort
• • •
|
|
OD Rotation
• • •
|
OS Rotation
• • •
|
|
Comments:
|
|
|
Trials Same as Wearing
|
|
|
Trials Dispensed Today
|
|
|
Brand of Lenses.
• • •
|
Base Curve.
• • •
|
|
OD Sph.
• • •
|
|
|
OD Cyl.
• • •
|
|
|
OD Axis.
• • •
|
VA
• • •
|
|
OD Rotation
• • •
|
|
|
OS Sph.
• • •
|
|
|
OS Cyl.
• • •
|
|
|
OS Axis.
• • •
|
VA
• • •
|
|
OS Rotation
• • •
|
|
|
OD Add.
• • •
|
OS Add.
• • •
|
|
Placement
• • •
|
Comfort
• • •
|
|
Comments
|
|
|
Trial Dispensed Today #2
|
|
|
Brand of Lenses:
• • •
|
Base Curve
• • •
|
|
OD Sph
• • •
|
|
|
OD Cyl
• • •
|
|
|
OD Axis
• • •
|
VA
• • •
|
|
OD Rotation
• • •
|
|
|
OS Sph
• • •
|
|
|
OS Cyl
• • •
|
|
|
OS Axis
• • •
|
VA
• • •
|
|
OS Rotation
• • •
|
|
|
OD Add
• • •
|
OS Add
• • •
|
|
Placement
• • •
|
Comfort
• • •
|
|
Comments
|
|
|
Trials To Be Ordered
|
|
|
Brands Of Lenses
• • •
|
Base Curve
• • •
|
|
OD Sph
• • •
|
|
|
OD Cyl
• • •
|
|
|
OD Axis
• • •
|
VA
• • •
|
|
|
OD Rotation
• • •
|
|
OS Sph
• • •
|
|
|
OS Cyl
• • •
|
|
|
OS Axis
• • •
|
VA
• • •
|
|
|
OS Rotation
• • •
|
|
OD Add
• • •
|
OS Add
• • •
|
|
Fit
• • •
|
Comfort
• • •
|
|
Comments:
|
|
|
Trial To Be Ordered #2
|
|
|
Brand of Lenses:
• • •
|
Base Curve
• • •
|
|
OD Sph
• • •
|
|
|
OD Cyl
• • •
|
|
|
OD Axis
• • •
|
|
|
OS Sph
• • •
|
|
|
OS Cyl
• • •
|
|
|
OS Axis
• • •
|
|
|
OD Add
• • •
|
OS Add
• • •
|
|
Comments
|
|
|
|
SLE:
|
|
Plan
|
|
|
Final CL RX Same as Trials
|
|
|
Instructions Given
• • •
|
Solution
• • •
|
|
Plan
• • •
|
|
|
Comments
|
|
