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HISTORY OF PRESENT ILLNESS
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SYSTEMIC MEDICATIONS
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OCULAR MEDICATIONS
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SMOKER YES/NO
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ALLERGIES
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TECH EXAM
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MENTAL STATUS
• • •
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NEAR GLASSES YES/NO
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CONTACT LENS WEARER YES/NO
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DISTANCE GLASSES YES/NO
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DISTANCE VISION OD
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DISTANCE VISION OS
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NEAR VISION OD
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NEAR VISION OS
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TA IOP OD/OS
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TONO IOP OD/OS
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IOP COMMENT / TIME
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PUPILS OD/OS
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PUPIL SHAPE / NOTE
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MOTILITY OD/OS
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COLOR VISION OD/OS
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CVF OD
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CVF OS
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AUTO REFRACTION OD
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AUTO REFRACTION OS
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CORNEAL CURVATURE OD
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CORNEAL CURVATURE OS
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RETINOSCOPY RX OD
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RETINOSCOPY RX OS
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MANIFEST OS RX
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MANIFEST RX OS
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MRx VISION OD
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MRx VISION OS
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HVF YES/NO
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OCT YES/NO
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ASCAN YES/NO
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CORNEAL THICKNESS OD/OS
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CORNEAL TOPOGRAPHY YES/NO
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CORNEAL CELL COUNT OD/OS
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DILATION OD
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DILATION OS
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DILATION TIME
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DILATION GTTS
• • •
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PROVIDER EXAM
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ORBIT OD
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ORBIT OS
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LACRIMAL GLANDS OD
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LACRIMAL GLANDS OS
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UPPER LID OD
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UPPER LID OS
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LOWER LID OD
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LOWER LID OS
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PALPREBRAL CONJUNCTIVA OD
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PALPREBRAL CONJUNCTIVA OS
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BULBAR CONJUNCTIVA OD
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BULBAR CONJUNCTIVA OS
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IRIS OD
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IRIS OS
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CORNEA OD
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CORNEA OS
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LENS OD
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LENS OS
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OPTIC DISC OD
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OPTIC DISC OS
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C/D RATIO OD
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C/D RATIO OS
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VITREOUS OD
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VITREOUS OS
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RETINA OD
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RETINA OS
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MACULA OD
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MACULA OD
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PLAN & SUMMARY
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