|
Habitual Rx
|
|
|
Primary Rx
|
|
|
Primary Rx
|
|
|
Primary Glasses Type
• • •
|
|
|
TOPCON Lenso OD
|
DVA OD
• • •
|
|
TOPCON Lenso OD ADD
|
Primary OD Prism
|
|
TOPCON Lenso OS
|
DVA OS
• • •
|
|
TOPCON Lenso OS ADD
|
Primary OS Prism
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Additional Notes
|
|
|
Additional glasses?
|
|
|
Secondary Rx
|
|
|
OD (Secondary Rx)
|
|
|
Secondary Glasses Type
• • •
|
|
|
Secondary OD Sphere
|
Secondary OD Cyl
|
|
Secondary OD Axis
|
Secondary DVA OD
• • •
|
|
Secondary ADD OD
|
Secondary OD Prism
|
|
OS (Secondary Rx)
|
|
|
Secondary OS Sphere
|
Secondary OS Cyl
|
|
Secondary OS Axis
|
Secondary DVA OS
• • •
|
|
Secondary ADD OS
|
Secondary OS Prism
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Additional Notes
|
|
|
Tertiary Rx
|
|
|
OD (Tertiary Rx)
|
|
|
Tertiary Glasses Type
• • •
|
|
|
Tertiary OD Sphere
|
Tertiary OD Cyl
|
|
Tertiary OD Axis
|
Tertiary DVA OD
• • •
|
|
Tertiary ADD OD
|
Tertiary OD Prism
|
|
OS (Tertiary Rx)
|
|
|
Tertiary OS Sphere
|
Tertiary OS Cyl
|
|
Tertiary OS Axis
|
Tertiary DVA OS
• • •
|
|
Tertiary ADD OS
|
Tertiary OS Prism
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Additional Notes
|
|
|
Contact Lens Rx
|
|
|
106| Patient wears Contact Lenses
|
107|What brand of contacts do you currently wear?
|
|
OD (Contact Lens)
|
|
|
CL OD Brand
|
OD Contact Lens Type / Wear Schedule
• • •
|
|
CL OD Sphere
|
CL OD Cyl
|
|
CL OD Axis
|
DVA OD
• • •
|
|
CL OD ADD
|
|
|
OS (Contact Lens)
|
|
|
CL OS Brand
|
OS Contact Lens Type / Wear Schedule
• • •
|
|
CL OS Sphere
|
CL OS Cyl
|
|
CL OS Axis
|
DVA OS
• • •
|
|
CL OS ADD
|
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
CL Notes
|
|
|
Entrance Testing
|
|
|
Entrance Testing
|
|
|
Unaided VA
|
|
|
Unaided DVA OD
• • •
|
Unaided DVA OS
• • •
|
|
Unaided DVA OU
• • •
|
Unaided NVA OU
• • •
|
|
Pupils
|
APD
|
|
EOMS
|
CVF
|
|
Additional Entrance Testing
|
|
|
DCT
|
NCT
|
|
NPC
|
Stereopsis
|
|
Color Vision
|
Additional Testing
|
|
Refraction
|
|
|
Autorefraction / Keratometry
|
|
|
Autorefraction / Keratometry
|
|
|
TOPCON Autorefraction OD
|
TOPCON Autorefraction OS
|
|
TOPCON Keratometry OD
|
TOPCON Keratometry OS
|
|
TOPCON PD DV OU
|
TOPCON PD NV OU
|
|
Additional Notes
|
|
|
Retinoscopy
|
|
|
Retinoscopy
|
|
|
OD Retinoscopy
|
OS Retinoscopy
|
|
Manifest
|
|
|
Manifest Rx
|
|
|
TOPCON Manifest OD
|
DVA CC OD
• • •
|
|
TOPCON Manifest OD ADD
|
Manifest OD Prism
|
|
TOPCON Manifest OS
|
DVA CC OS
• • •
|
|
TOPCON Manifest OS ADD
|
Manifest OS Prism
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Additional Manifest Notes
|
|
|
Trial Frame
|
|
|
Trial Frame
|
|
|
OD
|
|
|
Trial Frame OD Sphere
|
Trial Frame OD Cyl
|
|
Trial Frame OD Axis
|
Trial Frame ADD OD
|
|
OS
|
|
|
Trial Frame OS Sphere
|
Trial Frame OS Cyl
|
|
Trial Frame OS Axis
|
Trial Frame ADD OS
|
|
Trial Frame Comments
• • •
|
Trial Frame Comments
|
|
Additional Binocular Testing
|
|
|
Additional Binocular Testing
|
Additional Binocular Testing
|
|
Final Rx
|
|
|
Final same as Manifest?
|
|
|
Manifest OD
|
Manifest ADD OD
|
|
Manifest OS
|
Manifest ADD OS
|
|
Final same as Trial Frame?
|
|
|
Trial Frame OD Sphere
|
Trial Frame OD Cyl
|
|
Trial Frame OD Axis
|
Trial Frame OD ADD
|
|
Trial Frame OS Sphere
|
Trial Frame OS Cyl
|
|
Trial Frame OS Axis
|
Trial Frame OS ADD
|
|
Final same as Primary?
|
|
|
Primary OD Sphere
|
Primary OD ADD
|
|
Primary OS Sphere
|
Primary OS ADD
|
|
Final Same as Secondary?
|
|
|
Secondary OD Sphere
|
Secondary OD Cyl
|
|
Secondary OD Axis
|
Secondary OD ADD
|
|
Secondary OS Sphere
|
Secondary OS Cyl
|
|
Secondary OS Axis
|
Secondary OS ADD
|
|
Final Same as Tertiary?
|
|
|
Tertiary OD Sphere
|
Tertiary OD Cyl
|
|
Tertiary OD Axis
|
Tertiary OD ADD
|
|
Tertiary OS Sphere
|
Tertiary OS Cyl
|
|
Tertiary OS Axis
|
Teritary OS ADD
|
|
Enter new Final Rx
|
|
|
Primary Final Rx
|
|
|
Final Primary Type
• • •
|
|
|
OD (New Final Rx)
|
|
|
Final OD Sphere
|
Final OD Cyl
|
|
Final OD Axis
|
Final Rx ADD OD
|
|
OD Prism
|
|
|
OS (New Final Rx)
|
|
|
Final OS Sphere
|
Final OS Cyl
|
|
Final OS Axis
|
Final Rx ADD OS
|
|
OS Prism
|
|
|
Additional Notes
|
|
|
Additional Final Rx
|
|
|
Additional Final Glasses?
|
|
|
Final Secondary Type
• • •
|
|
|
OD (Secondary Final Rx)
|
|
|
Secondary Final OD Sphere
|
Secondary Final OD Cyl
|
|
Secondary Final OD Axis
|
Secondary Final Rx ADD OD
|
|
Secondary Final OD Prism
|
|
|
OS (Secondary Final Rx)
|
|
|
Secondary Final OS Sphere
|
Secondary Final OS Cyl
|
|
Secondary Final OS Axis
|
Secondary Final Rx ADD OS
|
|
Secondary Final OS Prism
|
|
|
OD (Tertiary Final Rx)
|
|
|
Tertiary Final Type
• • •
|
|
|
Tertiary OD Sphere
|
Tertiary Final OD Cyl
|
|
Tertiary Final OD Axis
|
Tertiary Final Rx ADD OD
|
|
Tertiary Final OD Prism
|
|
|
OS (Tertiary Final Rx)
|
|
|
Tertiary OS Sphere
|
Tertiary Final OS Cyl
|
|
Tertiary Final OS Axis
|
Tertiary Final Rx ADD OS
|
|
Tertiary Final OS Prism
|
|
|
Additional Final Glasses Notes
|
|
|
Additional Final Glasses Notes
|
|
|
Contact Lens Fitting
|
|
|
Contact Lens Fitting
|
Habitual Entered in Physical Exam Form
|
|
OD (Contact Lens)
|
|
|
OD Brand
|
OD Contact Lens Type / Wear Schedule
|
|
Habitual OD Sph
|
Habitual OD Cyl
|
|
Habitual OD Axis
|
VA
|
|
Habitual OD ADD
|
|
|
OD Over Refraction
|
OD Over Refraction VA
|
|
OD L-L
|
OD Centration
|
|
OD Movement
|
OD Rotation
|
|
OS (Contact Lens)
|
|
|
OS Brand
|
Contact Lens Type / Wear Schedule
|
|
Habitual OS Sph
|
Habitual OS Cyl
|
|
Habitual OS Axis
|
VA
|
|
Habitual OS ADD
|
|
|
OS Over Refraction
|
OS Over Refraction VA
|
|
OS L-L
|
OS Centration
|
|
OS Movement
|
OS Rotation
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Habitual CL Notes
|
|
|
Enter Habitual CL
|
|
|
Habitual OD Brand
|
OD Contact Lens Type / Wear Schedule
• • •
|
|
CL OD Sphere
|
CL OD Cyl
|
|
CL OD Axis
|
VA OD
• • •
|
|
CL OD ADD
|
|
|
OD Over Refraction
|
OD Over Refraction VA
|
|
OD L-L
|
OD Centration
|
|
OD Movement
|
OD Rotation
|
|
Habitual OS Brand
|
OS Contact Lens Type / Wear Schedule
• • •
|
|
CL OS Sphere
|
CL OS Cyl
|
|
CL OS Axis
|
VA OS
• • •
|
|
CL OS ADD
|
|
|
OS Over Refraction
|
OS Over Refraction VA
|
|
OS L-L
|
OS Centration
|
|
OS Movement
|
OS Rotation
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Habitual CL Notes
|
|
|
Trial 1
|
|
|
OD Trial 1
|
|
|
Trial 1 OD Brand
|
OD Contact Lens Type / Wear Schedule
• • •
|
|
Trial 1 OD Sphere
|
Trial 1 OD Cyl
|
|
Trial 1 OD Axis
|
Trial 1 VA OD
• • •
|
|
Trial 1 OD ADD
|
|
|
Trial 1 OD Over Refraction
|
Trial 1 OD Over Refraction VA
|
|
Trial 1 OD L-L
|
Trial 1 OD Centration
|
|
Trial 1 OD Movement
|
Trial 1 OD Rotation
|
|
OS Trial 1
|
|
|
Trial 1 OS Brand
|
OS Contact Lens Type / Wear Schedule
• • •
|
|
Trial 1 OS Sphere
|
Trial 1 OS Cyl
|
|
Trial 1 OS Axis
|
Trial 1 VA OS
• • •
|
|
Trial 1 OS ADD
|
|
|
Trial 1 OS Over Refraction
|
Trial 1 OS Over Refraction VA
|
|
Trial OS L-L
|
Trial OS Centration
|
|
Trial OS Movement
|
Trial OS Rotation
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Trial 1 Notes
|
|
|
Trial 2
|
|
|
OD Trial 2
|
|
|
Trial 2 OD Brand
|
OD Contact Lens Type / Wear Schedule
• • •
|
|
Trial 2 OD Sphere
|
Trial 2 OD Cyl
|
|
Trial 2 OD Axis
|
Trial 2 VA OD
• • •
|
|
Trial 2 OD ADD
|
|
|
Trial 2 OD Over Refraction
|
Trial 2 OD Over Refraction VA
|
|
Trial 2 OD L-L
|
Trial 2 OD Centration
|
|
Trial 2 OD Movement
|
Trial 2 OD Rotation
|
|
OS Trial 2
|
|
|
Trial 2 OS Brand
|
OS Contact Lens Type / Wear Schedule
• • •
|
|
Trial 2 OS Sphere
|
Trial 2 OS Cyl
|
|
Trial 2 OS Axis
|
Trial 2 VA OS
• • •
|
|
Trial 2 OS ADD
|
|
|
Trial 2 OS Over Refraction
|
Trial 2 OS Over Refraction VA
|
|
Trial 2 OS L-L
|
Trial 2 OS Centration
|
|
Trial 2 OS Movement
|
Trial 2 OS Rotation
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Trial 2 Notes
|
|
|
Trial 3
|
|
|
OD Trial 3
|
|
|
Trial 3 OD Brand
|
OD Contact Lens Type / Wear Schedule
• • •
|
|
Trial 3 OD Sphere
|
Trial 3 OD Cyl
|
|
Trial 3 OD Axis
|
Trial 3 VA OD
• • •
|
|
Trial 3 OD ADD
|
|
|
Trial 3 OD Over Refraction
|
Trial 3 OD Over Refraction VA
|
|
Trial 3 OD L-L
|
Trial 3 OD Centration
|
|
Trial 3 OD Movement
|
Trial 3 OD Rotation
|
|
OS Trial 3
|
|
|
Trial 3 OS Brand
|
OS Contact Lens Type / Wear Schedule
• • •
|
|
Trial 3 OS Sphere
|
Trial 3 OS Cyl
|
|
Trial 3 OS Axis
|
Trial 3 VA OS
• • •
|
|
Trial 3 OS ADD
|
|
|
Trial 3 OS Over Refraction
|
Trial 3 OS Over Refraction VA
|
|
Trial 3 OS L-L
|
Trial 3 OS Centration
|
|
Trial 3 OS Movement
|
Trial 3 OS Rotation
|
|
DVA OU
• • •
|
NVA OU
• • •
|
|
Trial 3 Notes
|
|
|
First Time CL Wearer - patient educated?
|
|
|
Trials to Be Ordered
|
Trials to be Ordered
|
|
Doctor Dispense? Yes / No
|
Optician Dispense? Yes / No
|
|
Final Contact Lens Rx
|
|
|
Final same as Habitual CLs?
|
|
|
Final same as Trial 1?
|
|
|
Trial 1 Final OD Brand
|
|
|
Trial 1 Final OD Sphere
|
Trial 1 Final OD Cyl
|
|
Trial 1 Final OD Axis
|
Trial 1 Final OD ADD
|
|
Trial 1 Final OS Brand
|
|
|
Trial 1 Final OS Sphere
|
Trial 1 Final OS Cyl
|
|
Trial 1 Final OS Axis
|
Trial 1 Final OS ADD
|
|
Final same as Trial 2?
|
|
|
Trial 2 Final OD Brand
|
|
|
Trial 2 Final OD Sphere
|
Trial 2 Final OD Cyl
|
|
Trial 2 Final OD Axis
|
Trial 2 Final OD ADD
|
|
Trial 2 Final OS Brand
|
|
|
Trial 2 Final OS Sphere
|
Trial 2 Final OS Cyl
|
|
Trial 2 Final OS Axis
|
Trial 2 Final OS ADD
|
|
Final same as Trial 3?
|
|
|
Trial 3 Final OD Brand
|
|
|
Trial 3 Final OD Sphere
|
Trial 3 Final OD Cyl
|
|
Trial 3 Final OD Axis
|
Trial 3 Final OD ADD
|
|
Trial 3 Final OS Brand
|
|
|
Trial 3 Final OS Sphere
|
Trial 3 Final OS Cyl
|
|
Trial 3 Final OS Axis
|
Trial 3 Final OS ADD
|
|
Enter New Final CL (and notes)
|
|
|
General CL Notes
|
|
|
General CL Notes
|
|
|
ANTERIOR SEG
|
|
|
Anterior Seg
|
|
|
Lids OD
|
Lids OS
|
|
Conjuctiva OD
|
Conjuctiva OS
|
|
Cornea OD
|
Cornea OS
|
|
Tear Film OD
|
Tear Film OS
|
|
Iris OD
|
Iris OS
|
|
A/C OD
|
A/C OS
|
|
Lens OD
|
Lens OS
|
|
Vitreous OD
|
Vitreous OS
|
|
Angles OD
|
Angles OS
|
|
Pertinent Negatives
• • •
|
Anterior Seg
|
|
TONOMETRY
|
|
|
Tonometry
|
|
|
Type
|
Drops
• • •
|
|
OD mmHg
|
OS mmHg
|
|
Time
|
Tonometry Notes
|
|
POSTERIOR SEG
|
|
|
Retina Evaluation
• • •
|
ED PT about risks/benefits/SE of DFE
|
|
Time
|
|
|
Posterior Seg
|
|
|
OD C/D Ratio
• • •
|
OS C/D Ratio
• • •
|
|
Optic Nerve OD
|
Optic Nerve OS
|
|
Macula OD
|
Macula OS
|
|
Vasculature OD
|
Vasculature OS
|
|
Vitreous OD
|
Vitreous OS
|
|
Periphery OD
|
Periphery OS
|
|
Pertinent Negatives
• • •
|
DFE Diagram
|
|
Assessment and Plan
|
|
|
Refractive Assessment
• • •
|
Rx Given For:
• • •
|
|
Primary Assessment & Plan Notes
|
Primary Plan
• • •
|
|
Secondary Assessment & Plan Notes
|
Secondary Plan
• • •
|
|
Tertiary Assessment & Plan Notes
|
Tertiary Plan
• • •
|
|
A&P Additional Notes:
|
|
