|
Uncorrected Visual Acuity OD
|
Uncorrected Visual Acuity OS
|
|
Pinhole acuity OD
|
Pinhole acuity OS
|
|
Autorefract/Retinoscopy OD
|
Autorefract/Retinoscopy OS
|
|
Keratometry OD
|
Keratometry OS
|
|
|
|
|
Habitual RX
|
Habitual RX
|
|
Habitual Rx:
|
Habitual VA OD
• • •
|
|
Habitual Rx:
|
Habitual VA OS
• • •
|
|
Near ADD:
|
Notes
|
|
|
|
|
IOP
|
IOP
|
|
IOP Type
|
Tonometry Notes
|
|
OD mmHg
|
OS mmHg
|
|
|
|
|
Entrance Tersting
|
Entrance Testing
|
|
Pupils
|
APD
|
|
EOMS
|
CVF
|
|
Cover Test
|
NPC
|
|
Color Vision WNL?
|
Stereopsis
|
|
Automated perimetry:
|
Notes:
|
|
Psych: Mood/Affect
|
Neuro: Oriented (person/place/time)
|
|
|
|
|
Subjective Refraction
|
SUBJECTIVE REFRACTION
|
|
OD Subj Refraction
|
VA OD
• • •
|
|
OS Subj Refraction
|
VA OS
• • •
|
|
ADD POWER
|
Near Acuity
|
|
|
|
|
Final RX
|
Enter new Final Rx
|
|
Final same as Subjective?
|
Final same as Habitual?
|
|
OD Final Refraction
|
VA OD
• • •
|
|
OS Final Refraction
|
VA OS
• • •
|
|
ADD POWER
|
Near Acuity
|
|
|
Notes:
|
|
Dilation
|
DFE
|
|
Dilation
• • •
|
ED PT about risks/benefits/SE of DFE
|
|
|
|
|
Anterior Segment
|
ANTERIOR SEGMENT
|
|
Lid OD WNL
|
comments
|
|
Lid OS WNL
|
comments
|
|
Conjunctiva/Sclera OD WNL?
|
comments
|
|
Conjunctiva/Sclera OS WNL?
|
comments
|
|
Cornea OD WNL?
|
comments
|
|
Cornea OS WNL?
|
comments
|
|
Ant chamber/Iris OD WNL?
|
comments
|
|
Ant chamber/Iris OS WNL?
|
comments
|
|
Lens OD Clear?
|
comments
|
|
Lens OS Clear?
|
comments
|
|
Anterior Segment OD
|
Anterior Segment OS
|
|
|
|
|
Posterior Segment
|
POSTERIOR SEGMENT
|
|
OD C/D Ratio
• • •
|
OS C/D Ratio
• • •
|
|
Optic Nerve OD WNL?
|
OD optic nerve comments
|
|
Optic Nerve OS WNL?
|
OS optic nerve comments
|
|
Vitreous OD WNL?
|
comments
|
|
Vitreous OS WNL?
|
comments
|
|
Macula OD WNL?
|
comments
|
|
Macula OS WNL?
|
comments
|
|
Vessels OD WNL?
|
OD Vessels
|
|
Vessels OS WNL?
|
OS Vessels
|
|
PERIPHERY OD
• • •
|
PERIPHERY OS
• • •
|
|
DFE Diagram
|
Final Overall Notes
|
