|
General WNL
|
General Abnormal
• • •
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General Comments
|
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Lensometry
|
|
|
Lens OD
|
Lens OS
|
|
Lens Comments:
|
|
|
Autorefraction
|
|
|
AR OD
|
AR OS
|
|
AR Comments:
|
|
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Subjective Refraction
|
|
|
MRx OD
|
MRx OS
|
|
MRx Comments:
|
|
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Visual Acuity
|
OD: label
|
|
UDVA OD
|
CDVA OD
|
|
UNVA OD
|
CNVA OD
|
|
PAM OD
|
OS: label
|
|
UDVA OS
|
CDVA OS
|
|
UNVA OS
|
CNVA OS
|
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PAM OS
|
|
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Glare Test
|
|
|
Va OD
|
Va OS
|
|
Pupils PERRL
|
comments
|
|
IOP
|
|
|
IOP OD
|
IOP OD Freewrite
|
|
IOP OS
|
IOP OS Freewrite
|
|
IOP time
|
IOP time Freewrite
|
|
IOP Method
|
IOP comments
|
|
Motility Full?
|
Motility Comments
|
|
Alignment
|
Alignment
|
|
Alignment Comments
|
|
|
VF Full?
|
VF Comments
|
|
Additional Testing?
|
|
|
Color Plates
|
|
|
OD correct
|
comments
|
|
OS correct
|
comments
|
|
Dilated?
|
Dilation Comments
|
|
Ocular Dominance
|
Ocular Dominance
|
|
|
Dominance Comments
|
|
Pachymetry
|
CCT measurements
/
|
|
SLE
|
SLE note:
|
|
Adnexa OD wnl
|
Adnexa OD Comments
|
|
Adnexa OS wnl
|
Adnexa OS Comments
|
|
L/L OD
• • •
|
L/L OD Comments
|
|
L/L OS
• • •
|
L/L OS Comments
|
|
C/S OD
• • •
|
C/S OD Comments
|
|
C/S OS
• • •
|
C/S OS Comments
|
|
K OD
• • •
|
K OD Comments
|
|
K OS
• • •
|
K OS Comments
|
|
Cornea Free Draw
|
|
|
AC OD
• • •
|
AC OD Comments
|
|
AC OS
• • •
|
AC OS Comments
|
|
Iris OD
• • •
|
Iris OD Comments
|
|
Iris Dilation OD
• • •
|
Iris Dilation OD Comments
|
|
Iris OS
• • •
|
Iris OS Comments
|
|
Iris Dilation OS
• • •
|
Iris Dilation OS Comments
|
|
Cataract OD?
|
IOL OD?
|
|
Cataract OD
• • •
|
Cataract OD Comments
|
|
IOL OD
• • •
|
IOL OD Comments
|
|
Cataract OS?
|
IOL OS?
|
|
Cataract OS
• • •
|
Cataract OS Comments
|
|
IOL OS
• • •
|
IOL OS Comments
|
|
Ant Vitreous OD
• • •
|
Ant Vit OD Comments
|
|
Ant Vitreous OS
• • •
|
Ant Vit OS Comments
|
|
FUNDUS EXAM
|
Comment:
|
|
Vitreous OD
• • •
|
Vit OD Comments
|
|
Vitreous OS
• • •
|
Vit OS Comments
|
|
cdr OD
|
ON OD
• • •
|
|
|
ON OD Comments
|
|
cdr OS
|
ON OS
• • •
|
|
|
ON OS Comments
|
|
Optic Nerve Free Draw
|
|
|
Macula OD
• • •
|
Macula OD Comments
|
|
Macula OS
• • •
|
Macula OS Comments
|
|
Vessels OD
• • •
|
Vessels OD Comments
|
|
Vessels OS
• • •
|
Vessels OS Comments
|
|
Periphery OD
• • •
|
Periphery OD Comments
|
|
Periphery OS
• • •
|
Periphery OS Comments
|
|
Notes:
|
|
|
Fundus OD Free Draw
|
Fundus OS Free Draw
|
