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Do you wear prescription glasses/contacts?
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If Yes
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FAR BOTH Eyes Without Rx
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FAR RIGHT Eye Without Rx
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FAR LEFT Eye Without Rx
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Near BOTH Eyes Without Rx
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Near RIGHT Eye Without Rx
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Near LEFT Eye Without Rx
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Far BOTH Eyes WITH Rx
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Far RIGHT Eye WITH Rx
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Far LEFT Eye WITH Rx
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Near BOTH Eyes WITH Rx
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Near RIGHT Eye WITH Rx
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Near LEFT Eye WITH Rx
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Color #6
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Depth Perception Card
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Depth Perception Card
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Peripheral: BOTH
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Peripheral Right
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Peripheral LEFT
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SCREENER
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NOTES:
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