|
Date
|
|
|
Ocular History
|
|
|
Uncorrected Distance Visual Acuity OD
|
Uncorrected Distance Visual Acuity OS
|
|
Uncorrected Near Visual Acuity OD
|
Uncorrected Visual Acuity OS
|
|
Current Glasses OD
|
Current Glasses OS
|
|
Current Distance Visual Acuity OD
|
Current Distance Visual Acuity OS
|
|
Current Near Visual Acuity OU
|
|
|
SUBJECTIVE REFRACTION
|
|
|
OD Subj Refraction
|
OS Subj Refraction
|
|
Best Corrected Distance Visual Acuity OD
|
Best Corrected Distance Visual Acuity OS
|
|
Add Power
|
Near Visual Acuity OU
|
|
Color Vision WNL?
|
Stereopsis
|
|
EOM motilities
|
Cover Test
|
|
Visual Field Test Type
|
|
|
Visual Field OD:
|
Visual Field OS:
|
|
Pupils PERRLA?
|
comments
|
|
IOP OD
|
IOP OS
|
|
Dilated
|
|
|
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
|
|
POSTERIOR SEGMENT
|
|
|
Vitreous OD WNL?
|
comments
|
|
Vitreous OS WNL?
|
comments
|
|
Optic Nerve OD WNL?
|
OD optic nerve comments
|
|
Optic Nerve OS WNL?
|
OS optic nerve comments
|
|
C/D ratio OD:
|
C/D ratio OS
|
|
Macula OD WNL?
|
comments
|
|
Macula OS WNL?
|
comments
|
|
Vessels OD WNL?
|
OD Vessels
|
|
Vessels OS WNL?
|
OS Vessels
|
|
Periphery OD WNL?
|
comments
|
|
Periphery OS WNL?
|
comments
|
|
Diagnosis
|
|
|
ICD-10 Code
|
ICD-10 Code
|
|
Diagnosis Summary
|
|
|
Prognosis
• • •
|
Overview
• • •
|
|
Assessment
|
|
|
Plan
|
|
|
John Stuart, Jr., OD
|
|
