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Start time
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Stop time
|
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Refraction time
|
Referring Doctor
|
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Chief complaint/HPI
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Diagnosis/ses
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Present low vision aid(s)
|
|
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ANALYSIS OF PRESENT Rx(s)
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OD
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OD ADD
|
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OD Prism
|
|
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OS
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OS ADD
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OS Prism
|
|
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Date of Rx
|
Glasses comments
|
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Contact lens comments
|
|
|
Glasses wearing
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|
|
OD
|
OD ADD
|
|
OD Prism
|
|
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OS
|
OS ADD
|
|
OS Prism
|
|
|
Date of Rx
|
Glasses comments
|
|
|
|
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Oriented to time/place/person
|
Mood & Affect
• • •
|
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Additional history
|
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VISUAL ACUITY
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Unaided visual acuity
|
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Distance
|
|
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Unaided O.D. (Distance)
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Chart and adaptations
• • •
|
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Unaided acuity OD comments
|
|
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Unaided O.S. (Distance)
|
Chart and adaptations
• • •
|
|
Unaided acuity OS comments
|
|
|
Unaided O.U. (Distance)
|
Chart and adaptations
• • •
|
|
Unaided acuity OU comments
|
|
|
Eccentric viewing used
|
Location of eccentric viewing
|
|
Near
|
|
|
Unaided O.D. (Near)
|
Chart and adaptations
• • •
|
|
Unaided near acuity OD comments
|
|
|
Unaided O.S. (Near)
|
Chart and adaptations
• • •
|
|
Unaided near acuity OS comments
|
|
|
Unaided O.U. (Near)
|
Chart and adaptations
• • •
|
|
Unaided near acuity OU comments
|
|
|
Smith-Kettlewell Read smallest print
|
|
|
Eye occlusion present?
|
Which eye?
|
|
Aided Ophthalmic Lens
|
|
|
Distance
|
|
|
O.D. aided ophthalmic lens (Distance)
|
Chart and adaptations
• • •
|
|
OD aided ophthalmic lens comments
|
|
|
O.S. aided ophthalmic lens (Distance)
|
Chart and adaptations
• • •
|
|
OS aided ophthalmic lens comments
|
|
|
OU aided ophthalmic lens (Distance)
|
Chart and adaptations
• • •
|
|
O.U. aided ophthalmic lens (Distance) comments
|
|
|
Near
|
|
|
O.D. aided ophthalmic lens (Near)
|
Chart and adaptations
• • •
|
|
OD aided ophthalmic lens (near) comments
|
|
|
O.S. aided ophthalmic lens (Near)
|
Chart and adaptations
• • •
|
|
OS aided ophthalmic lens (near) comments
|
|
|
OU aided ophthalmic Lens (Near)
|
Chart and adaptations
• • •
|
|
OU aided ophthalmic lens (near) comments
|
|
|
Aided low vision aid
|
|
|
Distance
|
|
|
OD aided low vision aid (Distance)
|
Chart and adaptations
• • •
|
|
OD low vision aid (Distance) comments
|
|
|
OS aided low vision aid (Distance)
|
Chart and adaptations
• • •
|
|
OS aided low vision aid (distance) comments
|
|
|
OU aided low vision aid (Distance)
|
Chart and adaptations
• • •
|
|
OU aided low vision aid (distance) comments
|
|
|
Near
|
|
|
OD aided low vision aid (Near)
|
Chart and adaptations
• • •
|
|
OD aided low vision aid (near) comments
|
|
|
OS aided low vision aid (Near)
|
Chart and adaptations
• • •
|
|
OS aided low vision aid (near) comments
|
|
|
OU aided low vision aid (Near)
|
Chart and adaptations
• • •
|
|
OU aided low vision aid (near) comments
|
|
|
Retinoscopy
|
|
|
Static retinoscopy- O.D.
|
Static retinoscopy - O.S.
|
|
Retinoscopy comments
|
|
|
Refraction
|
|
|
Distance Subjective - O.D.
|
Acuity OD
|
|
OD Prism
|
|
|
Distance Subjective - O.S.
|
Acuity OS
|
|
OS Prism
|
Complete/Incomplete Refraction
|
|
Subjective improvement upon trial frame
• • •
|
Refraction comments
|
|
Add power
|
P.D.
|
|
Contact lens(es)
|
|
|
Visual fields
|
|
|
Visual Fields
• • •
|
Field problems
• • •
|
|
Reliability
• • •
|
VF comments
|
|
Contrast Sensitivity- O.D.
|
Contrast sensitivity - O.S.
|
|
Contrast sensitivity - O.U.
|
Contrast chart used
|
|
Legally Blind
|
Legal blindness comments
|
