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PATIENT RECORD CARD
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Medical History
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Family
• • •
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Self
• • •
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List Any Allergies:
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Ocular:
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Medical:
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External Examination;
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Optometric Examination
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Old RX
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Auto-Refractor RX
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OD (left eye)
• • •
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OD (left eye)
• • •
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OS (right eye)
• • •
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OS (right eye)
• • •
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Visual Acuity
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Cycloplegic RX
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OD (left eye)
• • •
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OD (left eye)
• • •
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OS (right eye)
• • •
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OS (right eye)
• • •
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Biomicroscopy:
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Ophthalmoscopy:
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Patient Diagnosis:
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