|
Habitual Spectacle Rx
|
Never worn glasses
|
|
Patient came in wearing
• • •
|
Patient didn't bring glasses
|
|
OD +/-
|
OD Sph
|
|
OD Cyl
|
OD Axis
|
|
OS +/-
|
OS Sph
|
|
OS Cyl
|
OS Axis
|
|
ADD OU
|
Additional Comments:
|
|
DVA CC OD
• • •
|
PH VA OD
• • •
|
|
DVA CC OS
• • •
|
PH VA OS
• • •
|
|
NVA CC OD
• • •
|
NVA CC OS
• • •
|
|
Additional habitual glasses?
|
|
|
Glasses type/status
• • •
|
Comments:
|
|
Power OD
|
Power OS
|
|
Patient wears Contact Lenses
|
Wear Schedule
• • •
|
|
Brand:
|
CL Notes
|
|
CL Power OD
|
Notes OD:
|
|
CL Power OS
|
Notes OS:
|
|
Entrance Testing
|
Entrance Testing done?
|
|
Entrance VAs
|
|
|
DVA (cc)
|
|
|
cc OD
• • •
|
cc OS
• • •
|
|
cc OU
• • •
|
NVA (cc) Notes:
|
|
DVA (sc)
|
|
|
sc OD
• • •
|
sc OS
• • •
|
|
sc OU
• • •
|
NVA (sc) Notes:
|
|
VA CL
|
|
|
CL OD
• • •
|
CL OS
• • •
|
|
CL OU
• • •
|
NVA CL
|
|
Normal Color, Pupils, EOM's, CF's
|
Normal BV Testing
|
|
Color Vision
|
|
|
Stereopsis
|
|
|
DCT
|
Done with correction? Yes / No
|
|
NCT
|
Done with correction? Yes / No
|
|
NPC (enter value only, e.g. 7/10)
|
|
|
Pupils
|
Additional notes
|
|
APD
|
|
|
EOMS
|
EOMS Additional Notes
|
|
CVF
|
|
|
Additional Testing
|
|
|
Autorefraction/Keratometry
|
|
|
Autorefraction
|
DV PD
|
|
OD +/-
|
OD Sph
|
|
OD Cyl
|
OD Axis
|
|
|
DVA OD
• • •
|
|
OS +/-
|
OS Sph
|
|
OS Cyl
|
OS Axis
|
|
|
DVA OS
• • •
|
|
Auto Keratometry OD
|
Auto Keratometry OS
|
|
Retinoscopy
|
|
|
OD
|
OS
|
|
Retinoscopy Type
|
|
|
Subjective 1/Manifest Rx
|
|
|
Subjective 1:
|
|
|
OD +/-
|
OD Sph
|
|
OD Cyl
|
OD Axis
|
|
Prism OD
|
DVA CC OD
• • •
|
|
ADD OD
|
NVA CC OD
• • •
|
|
OS +/-
|
OS Sph
|
|
OS Cyl
|
OS Axis
|
|
Prism OS
|
DVA CC OS
• • •
|
|
ADD OS
|
NVA CC OS
• • •
|
|
Subjective or Trial Frame:
|
|
|
Trial Frame OD
|
Trial Frame OS
|
|
Trial Frame ADD:
|
Trial Frame Additional Comments
|
|
BCC
|
|
|
NRA
|
PRA
|
|
Horizontal Phoria
|
Vertical Phoria
|
|
Final Rx
|
|
|
Manifest is FINAL Rx
|
|
|
Final Rx OD Sign
|
Final Rx OD Sph
|
|
Final Rx OD Cyl
|
Final Rx OD Axis
|
|
Final Rx OD Prism
|
Final Rx OD ADD
|
|
Final OD DVA
|
|
|
Final Rx OS Sign
|
Final Rx OS Sph
|
|
Final Rx OS Cyl
|
Final Rx OS Axis
|
|
Final Rx OS Prism
|
Final Rx OS ADD
|
|
Final OS DVA
|
|
|
DV PD
|
Distance PD
|
|
Additional Final Glasses?
|
|
|
#1 Type
• • •
|
|
|
#1 OD
|
|
|
#1 OS
|
|
|
#1 ADD
|
|
|
#2 Type
• • •
|
|
|
#2 OD
|
|
|
#2 OS
|
|
|
#2 ADD
|
|
|
ANTERIOR SEG
|
Anterior Seg
|
|
LIDS WNL OD/OS
|
LIDS OTHER
|
|
CONJ White & Quiet OD/OS
|
CONJ OTHER
|
|
CORNEA Clear OD/OS
|
CORNEA OTHER
|
|
IRIS F & I OD/OS
|
IRIS OTHER
|
|
A/C WNL OD/OS
|
A/C OTHER
|
|
LENS Clear OD/OS
|
LENS OTHER
|
|
VITREOUS Clear OD/OS
|
VITREOUS OTHER
|
|
ANGLES Open w/Von Herrick OD/OS
|
ANGLES OTHER
|
|
TEAR FILM WNL OD/OS
|
TEAR FILM OTHER
|
|
Anterior Seg
|
|
|
TONOMETRY
|
Tonometry
|
|
Type
|
Drops
• • •
|
|
OD mmHg
|
OS mmHg
|
|
Time
|
Time Stamp
|
|
|
Last IOP's (for established pts, optional)
|
|
POSTERIOR SEG
|
Posterior Seg
|
|
Drops
• • •
|
Time Stamp
|
|
|
Time
|
|
PT declined dilation
|
Reason for dilation refusal?
|
|
ED PT about risks/benefits/SE of DFE
|
|
|
OD C/D ratio Vertical (or round)
|
OD C/D Horizontal
|
|
OS C/D ratio Vertical (or round)
|
OS C/D Horizontal
|
|
OPTIC DISC OD
|
OPTIC DISC OS
|
|
MACULA OD
|
MACULA OS
|
|
VESSELS OD
|
VESSELS OS
|
|
VITREOUS OD
|
VITREOUS OS
|
|
PERIPHERY OD
|
PERIPHERY OS
|
|
DFE Diagram
|
|
|
Final Overall Notes
|
|
|
Dr Knabb Electronic Signature:
|
Date Reviewed & Signed
|
