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Contact Lens Evaluation
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Contact Lens Chief Complaint
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Reason for today visit
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Eye Dominance
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Habitual CL Rx
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Patient replaces lenses
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Wear Schedule
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Habitual Brand OU
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Notes:
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OD Sphere
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OD Cyl
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OD Axis
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DVA OD
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ADD OD
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NVA OD
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OS Sphere
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OS Cyl
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OS Axis
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DVA OS
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ADD OS
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NVA OS
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Fitting Assessment OD
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Rotation OD
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Fitting Assessment OS
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Rotation OS
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Comments (ORx, fit, comfort, Slit lamp comments):
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New Fitting 1 (Same BRAND OU)
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Brand OU
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BC OU
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DIA OU
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OD Sphere
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OD Cyl
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OD Axis
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ADD OD (samebrand)
• • •
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DVA OD
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ORx and VA Notes OD:
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OS Sphere
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OS Cyl
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OS Axis
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ADD OS (same brand)
• • •
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DVA OS
• • •
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ORx and VA Notes OS:
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DVA OU
• • •
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NVA OU
• • •
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Fitting Assessment OD
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Rotation OD
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Fitting Assessment OS
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Rotation OS
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Notes:
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Plan
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New Fitting 1 (Different Brand OU)
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Trial 1 Brand OD
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BC OD
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DIA OD
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Trial 1 Brand OS
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BC OS
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DIA OS
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OD Sphere
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OD Cyl
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OD Axis
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ADD OD
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DVA OD
• • •
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OS Sphere
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OS Cyl
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OS Axis
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ADD OS
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DVA OS
• • •
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DVA OU
• • •
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NVA OU
• • •
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Fitting Assessment OD
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Rotation OD
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Fitting Assessment OS
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Rotation OS
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Notes:
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Plan:
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New Fitting 2
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BRAND (Fitting 2)
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BC/DIA: (Fitting 2)
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Power OD: (Fitting 2)
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Power OS: (Fitting 2)
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Replacement Schedule: (Fitting 2)
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Fitting Assessment OD
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Rotation OD
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Fitting Assessment OS
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Rotation OS
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Notes Fitting 2
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Plan:
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