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Chief Complaint
|
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HPI
|
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A&OX3
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MHx/FHx/Meds/Allergies REVIEWED
|
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LENSOMETRY OD / OS
|
ADD (+)
|
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AutoKeratometry OD
/
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AutoKeratometry OS
/
|
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Retinoscopy or Autorefraction OD / OS
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Type of Correction for VAcc
|
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• • •
|
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VA @ Dist. OD
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VA @ Dist. OS
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VA @ Dist. OU
|
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• • •
|
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VA @ Near OD
|
VA @ Near OS
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VA @ Near OU
|
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COLOR VISION (Ishihara)
|
STEREOVISION
• • •
|
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PUPILS
• • •
|
EOM
• • •
|
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COVER TEST
• • •
|
CVF
• • •
|
|
IOP (NCT) OD/OS
/
|
IOP (Goldmann) OD/OS
/
|
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BP
/
|
WELLNESS VF SCREENING
• • •
|
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PRE-AURICULAR NODE; Palpable?
|
NEUROLOGIC
• • •
|
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SUBJECTIVE REFRACT
|
|
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SUBJECTIVE REFRACTION OD
|
VA OD
|
|
SUBJECTIVE REFRACTION OS
|
VA OS
|
|
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VA OU
|
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ADD (+)
|
NEAR VA OU
|
|
NRA(+)/PRA(-)
|
BINOCULAR BALANCED FINAL SRX
|
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PHORIA DIST
|
PHORIA NEAR
|
|
WET/CYCLO
|
CYCLO VA
|
|
NPC
|
|
|
ANT SEG?
|
|
|
OCULAR ADNEXA
• • •
|
OA Comments:
|
|
EYELIDS/LASHES
• • •
|
Lids/Lashes Comments
|
|
SCLERA/EPISCLERA
• • •
|
S/E Comments
|
|
CONJUNCTIVA
• • •
|
Conj Comments
|
|
CORNEA
• • •
|
Cornea Comments
|
|
IRIS
• • •
|
Iris Comments
|
|
ANTERIOR CHAMBER
• • •
|
AC Comments
|
|
LENS
• • •
|
Lens Comments
|
|
ANGLE ESTIMATE
• • •
|
Gonioscopy
|
|
Anterior Segment OD
|
Anterior Segment OS
|
|
Post Seg?
|
Lens Used
• • •
|
|
Dilation Drops
|
Maestro2
• • •
|
|
C/D Ratio OD
/
|
C/D Ratio OS
/
|
|
OPTIC NERVE
• • •
|
ONH Comments
|
|
MACULA
• • •
|
Macula Comments:
|
|
FOVEAL REFLEX OU?
|
|
|
VITREOUS
• • •
|
Vitreous Comments
|
|
POSTERIOR POLE
• • •
|
Post Pole Comments
|
|
VASCULATURE
• • •
|
Vasculature Comments
|
|
PERIPHERY
• • •
|
Periphery Comments
|
|
Retina OD
|
Retina OS
|
|
Rx given OD
|
Rx given OS
|
|
Assesment
• • •
|
Assesment
|
|
Plan
• • •
|
Plan
|
