|
Primary Rx
|
Primary Glasses Type
|
|
Primary OD Sign
|
Primary OD Sph
|
|
Primary OD Cyl
|
Primary OD Axis
|
|
Primary ADD OD
|
VA OD
• • •
|
|
Primary OD Prism
|
|
|
Primary OS Sign
|
Primary OS Sph
|
|
Primary OS Cyl
|
Primary OS Axis
|
|
Primary ADD OS
|
VA OS
• • •
|
|
Primary OS Prism
|
|
|
VA OU
• • •
|
|
|
Additional Notes
|
|
|
Additional glasses?
|
|
|
Secondary Glasses Type
• • •
|
|
|
Secondary OD Sign
|
Secondary OD Sph
|
|
Secondary OD Cyl
|
Secondary OD Axis
|
|
Secondary ADD OD
|
VA OD
• • •
|
|
Secondary OD Prism
|
|
|
Secondary OS Sign
|
Secondary OS Sph
|
|
Secondary OS Cyl
|
Secondary OS Axis
|
|
Secondary ADD OS
|
Secondary VA OS
• • •
|
|
Secondary OS Prism
|
|
|
VA OU
• • •
|
|
|
Additional Notes
|
|
|
Tertiary Glasses 2 Type
• • •
|
|
|
Tertiary OD Sign
|
Tertiary OD Sph
|
|
Tertiary OD Cyl
|
Tertiary OD Axis
|
|
Tertiary ADD OD
|
Tertiary VA OD
• • •
|
|
Tertiary OD Prism
|
|
|
Tertiary OS Sign
|
Tertiary OS Sph
|
|
Tertiary OS Cyl
|
Tertiary OS Axis
|
|
Tertiary ADD OS
|
Tertiary VA OS
• • •
|
|
Tertiary OS Prism
|
|
|
Tertiary VA OU
• • •
|
|
|
Additional Notes
|
|
|
Patient wears Contact Lenses
|
Contact Lens Type / Wear Schedule
• • •
|
|
Brand
|
CL Notes
|
|
CL OD Sign
|
CL OD Sph
|
|
CL OD Cyl
|
CL OD Axis
|
|
CL OD ADD
|
VA OD
• • •
|
|
CL OS Sign
|
CL OS Sph
|
|
CL OS Cyl
|
CL OS Axis
|
|
CL OS ADD
|
VA OS
• • •
|
|
VA OU
• • •
|
|
|
Entrance Testing
|
|
|
VA SC
|
|
|
VA SC OD
• • •
|
VA SC OS
• • •
|
|
VA SC OU
• • •
|
|
|
Pupils
|
APD
|
|
EOMS
|
CVF
|
|
Additional Entrance Testing
|
|
|
NPC
|
|
|
DCT
|
|
|
NCT
|
|
|
Stereopsis
|
|
|
Color Vision
|
|
|
Additional Testing
|
|
|
Autorefraction
|
Autorefraction
|
|
OD Sign
|
OD Sph
|
|
OD Cyl
|
OD Axis
|
|
OS Sign
|
OS Sph
|
|
OS Cyl
|
OS Axis
|
|
Retinoscopy
|
Retinoscopy Type
|
|
OD
|
OS
|
|
Manifest Rx
|
|
|
Manifest OD Sign
|
Manifest OD Sph
|
|
Manifest OD Cyl
|
Manifest OD Axis
|
|
Manifest ADD OD
|
DVA CC OD
• • •
|
|
Manifest OS Sign
|
Manifest OS Sph
|
|
Manifest OS Cyl
|
Manifest OS Axis
|
|
Manifest ADD OS
|
DVA CC OS
• • •
|
|
Trial Frame
|
|
|
Trial OD Sign
|
Trial OD Sph
|
|
Trial OD Cyl
|
Trial OD Axis
|
|
Trial Frame ADD OD
|
|
|
Trial Frame OS Sign
|
Trial Frame OS Sph
|
|
Trial Frame OS Cyl
|
Trial Frame OS Axis
|
|
Trial Frame ADD OS
|
|
|
Trial Frame Comments
• • •
|
|
|
Additional Binocular Testing
|
|
|
Prism OD
|
Prism OS
|
|
Final Rx
|
|
|
Final same as Manifest?
|
|
|
Final same as Trial Frame?
|
|
|
Final same as Primary?
|
|
|
Final Same as Secondary
|
Final Same as Tertiary
|
|
Enter new Final Rx
|
|
|
Final OD Sign
|
Final OD Sph
|
|
Final OD Cyl
|
Final OD Axis
|
|
Final Rx ADD OD
|
OD Prism
|
|
Final OS Sign
|
Final OS Sph
|
|
Final OS Cyl
|
Final OS Axis
|
|
Final Rx ADD OS
|
OS Prism
|
|
Additional Final Glasses?
|
Final Secondary Type
• • •
|
|
Secondary Final OD Sign
|
Secondary Final OD Sph
|
|
Secondary Final OD Cyl
|
Secondary Final OD Axis
|
|
Secondary Final Rx ADD OD
|
Secondary Final OD Prism
|
|
Secondary Final OS Sign
|
Secondary Final OS Sph
|
|
Secondary Final OS Cyl
|
Secondary Final OS Axis
|
|
Secondary Final Rx ADD OS
|
Secondary Final OS Prism
|
|
Tertiary Final Type
• • •
|
|
|
Tertiary Final OD Sign
|
Tertiary Final OD Sph
|
|
Tertiary Final OD Cyl
|
Tertiary Final OD Axis
|
|
Tertiary Final Rx ADD OD
|
Tertiary Final OD Prism
|
|
Tertiary Final OS Sign
|
Tertiary Final OS Sph
|
|
Tertiary Final OS Cyl
|
Tertiary Final OS Axis
|
|
Tertiary Final Rx ADD OS
|
Tertiary Final OS Prism
|
|
PD DV
|
|
|
PD DV OD
|
PD DV OS
|
|
PD DV OU
|
|
|
PD IV
|
|
|
PD IV OD
|
PD IV OS
|
|
PD IV OU
|
|
|
PD NV
|
|
|
PD NV OD
|
PD NV OS
|
|
PD NV OU
|
|
|
ANTERIOR SEG
|
Anterior Seg
|
|
Lids WNL OD/OS
|
LIDS OTHER
|
|
Conj WNL OD/OS
|
CONJ OTHER
|
|
Cornea WNL OD/OS
|
CORNEA OTHER
|
|
Iris flat + intact OD/OS
|
IRIS OTHER
|
|
A/C D+Q OD/OS
|
A/C OTHER
|
|
Lens Clear OD/OS
|
LENS OTHER
|
|
Vitreous Clear OD/OS
|
VITREOUS OTHER
|
|
Angles Open OD/OS
|
ANGLES OTHER
|
|
Tear Film WNL OD/OS
|
TEAR FILM OTHER
|
|
Anterior Seg
|
|
|
TONOMETRY
|
Tonometry
|
|
Type
|
Drops
• • •
|
|
OD mmHg
|
OS mmHg
|
|
Time
|
Tonometry Notes
|
|
POSTERIOR SEG
|
|
|
Dilation
• • •
|
ED PT about risks/benefits/SE of DFE
|
|
Post Seg All Normal
|
Time
|
|
Posterior Seg Notes
|
|
|
OD C/D Ratio
• • •
|
OS C/D Ratio
• • •
|
|
OPTIC NERVE OD
• • •
|
OPTIC NERVE OS
• • •
|
|
OPTIC DISC OD
|
OPTIC DISC OS
|
|
MACULA OD
• • •
|
MACULA OS
• • •
|
|
VASCULATURE OD
• • •
|
VASCULATURE OS
• • •
|
|
VITREOUS OD
• • •
|
VITREOUS OS
• • •
|
|
PERIPHERY OD
• • •
|
PERIPHERY OS
• • •
|
|
DFE Diagram
|
|
|
Final Overall Notes
|
|
