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Review of PMHx/FHx/allergies?
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Patient alert, mood normal, and oriented x 3?
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Reason for visit
• • •
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Chief Complaint
• • •
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Location
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Context
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Duration
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Severity
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Timing
• • •
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Modifiers
• • •
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Associated symptoms
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Hx/Medical Review
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PCP
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LPE
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Last ECP
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LEE
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Patient Medical Hx
• • •
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Medical History Notes
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Family Medical History
• • •
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Family Medical History Notes
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Patient Ocular History
• • •
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Ocular History Notes
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Family Ocular History
• • •
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Family Ocular History Notes
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Current Rx'd meds
• • •
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Other Rx meds
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Current OTC meds
• • •
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Other OTC meds
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Ocular meds
• • •
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Other ocular meds
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Allergies
• • •
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Other Allergies
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Social History
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Smoker?
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Drinks alcohol?
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Uses unprescribed drugs?
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Exposure to STD's?
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PRE-TESTS
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PRE-TESTS
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VF OD
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VF OS
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Pre-testing
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Pre-Testing Documents
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Autorefraction
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Autorefraction
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Autorefraction OD sphere
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Autorefraction OD cyl
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Autorefraction OD axis
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Autorefraction OS sphere
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Autorefraction OS cyl
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Autorefraction OS axis
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PD
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Keratometry
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Keratometry
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K steep OD
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K flat OD
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K flat axis OD
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K steep OS
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K flat OS
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K flat axis OS
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Current Glasses
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Current glasses OD sphere
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Current glasses OD cyl
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Current glasses OD axis
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Glasses add OD
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Current glasses OS sphere
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Current glasses OS cyl
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Current glasses OS axis
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Glasses add OS
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Other Rx OD
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Other Rx OS
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NCT/IOP
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NCT OD
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NCT OS
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Additional IOP performed?
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IOP method
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IOP OD
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IOP OS
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IOP w/ manual time entry
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IOP type
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Time of IOP
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IOP OD
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IOP OS
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Stereo/Color Testing
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Was Stereo Testing Normal?
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Stereo Testing Notes
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Was Color Vision Normal?
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Color Vision Notes
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Visual Fields
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Visual Fields
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VF Screening
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Was Visual Field Screening Normal OD?
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VF Screening Results OD
• • •
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Was Visual Field Screening Normal OS?
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VF Screening Results OS
• • •
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CVF Performed?
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CVF Results
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Visual Acuity
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Uncorrected VA
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Uncorrected DVA OD
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NVA uncorrected OD
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Uncorrected DVA OS
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NVA uncorrected OS
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Pinhole VA OD
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Pinhole VA OS
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Corrected VA
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Corrected VA measured through...
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Current specs OD sphere
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Current specs OD cyl
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Current specs OD axis
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Corrected DVA OD
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Current specs OS sphere
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Current specs OS cyl
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Current specs OS axis
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Corrected DVA OS
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Current specs OD add
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Corrected NVA OD
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Current specs OS add
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Corrected NVA OS
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Pinhole VA OD
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Pinhole VA OS
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VA through CL's
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Habitual CL type OD
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Habitual CL power OD
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DVA OD w/ CL
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NVA OD w/ CL
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Habitual CL type OS
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Habitual CL power OS
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DVA OS w/ CL
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NVA OS w/ CL
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PERRLA OU?
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Pupil Notes
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EOM's full and unrestricted OU?
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EOM Notes
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NPC
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NPC Break
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Cover Test Distance
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Amount of Distance Phoria/Tropia
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Cover Test Near
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Amount of Near Phoria/Tropia
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REFRACTION
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Refraction/Phorometry Performed?
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Manifest/Dry
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Manifest Refraction OD sphere
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Manifest Refraction OD cyl
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Manifest Refraction OD axis
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Distance BCVA OD
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Manifest Refraction OS sphere
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Manifest Refraction OS cyl
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Manifest Refraction OS axis
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Distance BCVA OS
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Manifest Add OD
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Near BCVA OD
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Manifest Add OS
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Near BCVA OS
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Wet
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Cycloplege Performed?
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Cyclo refraction OD sphere
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Cyclo refraction OD cyl
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Cyclo refraction OD axis
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Cycloplegic VA OD
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Cyclo refraction OS sphere
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Cyclo refraction OS cyl
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Cyclo refraction OS axis
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Cycloplegic VA OS
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Use Manifest as Final Rx?
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Final Rx sphere OD (mft)
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Final Rx cyl OD (mft)
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Final Rx axis OD (mft)
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Final Rx sphere OS (mft)
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Final Rx cyl OS (mft)
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Final Rx axis OS (mft)
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Final add OD (mft)
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Final add OS (mft)
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Final Rx other than Manifest?
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Final Rx OD sphere
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Final Rx OD cyl
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Final Rx OD axis
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Final Add OD
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Final Rx OS sphere
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Final Rx OS cyl
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Final Rx OS axis
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Final Add OS
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Rx Notes OD
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Rx Notes OS
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Accommodation/Phorometry
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Accommodation &/or Phorometry?
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Near Testing Through...
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Accommodative Amps
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NRA
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PRA
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Accomodation Notes
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Other Phorometry Findings
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DILATION?
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DFE performed today
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DFE today w/ manual time entry
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Dilation Drops
• • •
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Dilation Drops
• • •
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Time of DFE
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Dilation not performed
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Reason for not dilating
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Last DFE?
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ANTERIOR SEG
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Anterior Segment
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All anterior seg healthy OU?
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Anter Seg Detailed
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Lids/Lashes Normal OU?
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Lids and Lashes OD
• • •
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Lids and Lashes OS
• • •
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Tear Film Normal OU?
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Tear Film OD
• • •
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Tear Film OS
• • •
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Corneas Normal OU?
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Cornea OD
• • •
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Cornea OS
• • •
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OD Cornea Notes
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OS Cornea Notes
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Conjunctivae Normal OU?
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Conjunctivae OD
• • •
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Conjunctivae OS
• • •
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OD Conjunctiva Notes
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OS Conjunctiva Notes
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Anterior Chambers Normal OU?
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Anterior Chamber OD
• • •
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Anterior Chamber OS
• • •
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VH Angle OD
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VH Angle OS
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Irises Normal OU?
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Iris OD
• • •
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Iris OS
• • •
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Lenses Clear OU?
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Lens OD
• • •
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Lens OS
• • •
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Anterior Seg
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Anterior Seg Notes
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POSTERIOR SEG
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Posterior Seg Evaluated?
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Fundus lenses used
• • •
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Posterior seg healthy (undilated)
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Posterior seg healthy (dilated)
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C/D ratios
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OD C/D ratio Vertical (or round)
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OD C/D Horizontal
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OS C/D ratio Vertical (or round)
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OS C/D Horizontal
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Post Seg Detailed
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Optic Discs Normal OU?
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Optic Disc OD
• • •
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Optic Disc OS
• • •
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Optic disc notes OD
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Optic disc notes OS
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Retinal Vessels Normal OU?
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Retinal Vessels OD
• • •
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Retinal Vessels OS
• • •
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Maculae Normal OU?
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Macula OD
• • •
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Macula OS
• • •
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OD Macula Notes
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OS Macula Notes
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Vitreous Normal OU?
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Vitreous OD
• • •
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Vitreous OS
• • •
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Posterior Pole WNL OU?
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Posterior Pole OD
• • •
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Posterior Pole OS
• • •
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Periphery WNL OU?
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Periphery OD
• • •
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Periphery OS
• • •
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Posterior Seg
|
Posterior Seg Notes
|
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Ancillary Tests
|
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Ancillary Tests
|
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Threshold VF
|
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Threshold VF OD
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VF results OD
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Threshold VF OS
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VF results OS
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GDX
|
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GDX results OD
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GDX notes OD
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GDX results OS
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GDX notes OS
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Retinal Photos
|
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Retinal Photo OD
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Photo notes OD
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Retinal Photo OS
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Photo notes OS
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Lens #1 fit today OD (or currently wearing)
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Sphere OD
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Cyl OD
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Axis OD
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Lens #1 fit today OS (or currently wearing)
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Sphere OS
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ASSESSMENT
|
|
|
Refractive Diagnosis?
|
Refractive Dx
• • •
|
|
Systemic Diagnosis?
|
Systemic Dx
• • •
|
|
Medical Ocular Diagnosis?
|
Medical ocular Dx
• • •
|
|
PLAN
|
|
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Plan
• • •
|
|
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Medical Rx given?
|
Medication Name
• • •
|
|
Sig
|
PO or which eye
|
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Frequency of use
|
Duration of use
|
|
Medical Rx Notes
|
|
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Pt Ed?
|
Pt Ed Given
• • •
|
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Follow Up #1 Reason
|
Follow-up #1 time frame
|
|
Follow Up #2 Reason
|
Follow up #2 time frame
• • •
|
|
Referral Made?
|
|
|
Refer to
|
Referral for
• • •
|
|
Referral Form
|
|
|
Miscellaneous Notes?
|
Notes
|
|
Electronic Signature
|
|
