|
Habitual Correction
|
Verification
• • •
|
|
Spec Rx OD
|
Spec Rx OS
|
|
How old?
|
Comments
|
|
Spec Rx 2 OD
|
Spec Rx 2 OS
|
|
How old?
|
Comments
|
|
CL Brand OD
• • •
|
Rx/comments
|
|
CL Brand OS
• • •
|
Rx/comments
|
|
How old?
|
Replace every x?
|
|
wear time (h/d)
|
satisfaction
• • •
|
|
Comments
|
|
|
Visual Acuities
|
|
|
Uncorrected:
|
|
|
DVAsc OD 20/
|
DVAsc OS 20/
|
|
OU 20/
|
PH
|
|
NVAsc OD 20/
|
NVAsc OS 20/
|
|
OU 20/
|
Uncorrected comments
|
|
Corrected:
|
VAcc with
• • •
|
|
DVAcc OD 20/
|
DVAcc OS 20/
|
|
OU 20/
|
PH
|
|
NVAcc OD 20/
|
NVAcc OS 20/
|
|
OU 20/
|
Corrected comments
|
|
Push Up Amp OD (100/cm)
|
Amp OS (min=15-1/4xAge)
|
|
Entrance Tests
|
|
|
Color vision
• • •
|
Comments
|
|
Cover Test
• • •
|
Comments
|
|
Stereo
• • •
|
W4D if <40sec or Stereo comments
|
|
NPC (norm=5/7cm)
/
|
Comments
|
|
Hirschberg ortho? (1mm=22pd)
|
Comments
|
|
EOM
• • •
|
Comments
|
|
PUPILS
• • •
|
Comments
|
|
Finger Count Fields normal?
|
Comments
|
|
Refraction
|
|
|
A/R OD
|
20/
|
|
A/R OS
|
20/
|
|
Auto-K OD
|
Auto-K OS
|
|
Ret OD
|
20/
|
|
Ret OS
|
20/
|
|
Comments
|
|
|
Subj Refract OD
|
20/
|
|
Subj Refract OS
|
20/
|
|
OU 20/
|
Comments
|
|
Add(+)
|
Add comments
|
|
Near OD 20/
|
Near OS 20/
|
|
Final Spec Rx
|
Other refraction
|
|
Functional Tests
|
|
|
NRA(+)/PRA(-)
|
Sight dominance
• • •
|
|
Phoria Distance
|
Phoria Near
|
|
|
|
|
Palpable nodes?
|
Lymph Node Comments
|
|
Ant Seg Exam
|
Ant Seg all WNL (angle grade)
• • •
|
|
Adnexa
• • •
|
Adnexa Comments
|
|
Lids/Lashes
• • •
|
Lids/Lashes Comments
|
|
Conj
• • •
|
Conj Comments
|
|
Sclera
• • •
|
Sclera Comments
|
|
K
• • •
|
Cornea Comments
|
|
AC
• • •
|
AC Comments
|
|
Van Herick OD/OS
/
|
Angle comments
|
|
Iris
• • •
|
Iris Comments
|
|
Lens
• • •
|
Lens Comments
|
|
NCT OD/OS
/
|
GAT OD/OS
/
|
|
IOP drops
• • •
|
Time
|
|
Gonio
|
Post Seg all WNL (C/D ratio)
• • •
|
|
Post Seg Exam
|
Viewed by
• • •
|
|
Vitreous
• • •
|
Vitreous Comments
|
|
C/D ratio OD 0.x
|
C/D ratio OS 0.x
|
|
ONH
• • •
|
ONH Comments
|
|
Vasculature
• • •
|
Vasculature Comments
|
|
Macula
• • •
|
Macula Comments
|
|
Post Pole
• • •
|
Post Pole Comments
|
|
DFE performed?
|
DFE drops
• • •
|
|
Periphery
• • •
|
Periphery Comments
|
|
|
|
|
Comments
|
|
|
Anterior Seg / Fundus Drawing
|
|
