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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

H&P Physical Exam Medical Form

Independent Doctor of Optometry

dr Oksana Sova version

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Published: March 24, 2021, 12:08 p.m.
Doctor: Dr. History Physical
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