|
Date of Last Eye Exam
|
Last Eye Exam Location / Doctor
|
|
Patient Mood / Effect
|
Patient Oriented x 3
|
|
Entering Spectacle Rx OD
|
Entering Spectacle RX OS
|
|
Entering CL Rx OD
|
Entering CL Rx OS
|
|
Entering DVA w/correction OD
|
Entering DVA w/correction OS
|
|
Entering DVA w/o correction OD
|
Presenting VA w/o correction OS
|
|
PINHOLE DVA OD
|
PINHOLE DVA OS
|
|
Near Visual Acuity Measured
|
Near Visual Acuity
/
|
|
STEREO ACUITY
• • •
|
COLOR VISION ISHIHARA
• • •
|
|
Keratometry OD
/
|
Keratometry OS
/
|
|
Autorefraction OD
|
Autorefraction OS
|
|
Manifest Refraction OD
|
Manifest Refraction OS
|
|
BCVA with Manifest Refraction OD
|
BCVA with Manifest Refraction OS
|
|
Tentative Near Add OU
|
Near Corrected BCVA OU
/
|
|
|
|
|
Pupil Diameter/Testing OD
|
Pupil Diameter / Testing OS
|
|
APD Present:
|
VFF to FCC
|
|
Confrontation Visual Field OD
• • •
|
Confrontation Visual Field OS
• • •
|
|
Extraocular Muscle Testing OD
|
Extraocular Muscle Testing OS
|
|
Tonometry Method OU
|
IOP OD / OS
/
|
|
Anterior Chamber Depth OD
|
Anterior Chamber Depth OS
|
|
Lid OD
• • •
|
Lid OS
• • •
|
|
Anterior Segment OD
• • •
|
Anterior Segment OS
• • •
|
|
Conjunctiva/Sclera OD
• • •
|
Conjunctiva/Sclera OS
• • •
|
|
Cornea OD
• • •
|
Cornea OS
• • •
|
|
Anterior Chamber OD
• • •
|
Anterior Chamber OS
• • •
|
|
Iris OD
• • •
|
Iris OS
• • •
|
|
Lens OD
• • •
|
Lens OS
• • •
|
|
Anterior Segment Comments OD
|
Anterior Segment Comments OS
|
|
|
|
|
DILATION DROPS OD
• • •
|
DILATION DROPS OS
• • •
|
|
Posterior Segment OD
• • •
|
Posterior Segment OS
• • •
|
|
Vitreous OD
• • •
|
Vitreous OS
• • •
|
|
Cup to Disc Ratio OD
|
Cup to Disc Ratio OS
|
|
Optic Nerve OD
• • •
|
Optic Nerve OS
• • •
|
|
Macula OD
• • •
|
Macula OS
• • •
|
|
Vessels OD
• • •
|
Vessels OS
• • •
|
|
Periphery OD
• • •
|
Periphery OS
• • •
|
|
Posterior Segment Comments OD
|
Posterior Segment Comments OS
|
|
|
|
|
Pachymetry OD
|
Pachymetry OS
|
|
Goinioscopy OD
|
Gonioscopy OS
|
|
Gonio OD comments
|
Gonio OS Comments
|
|
Blood Pressure
/
|
Amsler Grid
|
|
Contact Lens Fit OD - Lens Type
|
Contact Lens Fit OS - Type
|
|
BCVA with CL OD
|
BCVA with CL OS
|
|
CL Fit Evaluation / Comments OD
• • •
|
CL Fit Evaluation/ Comments OS
• • •
|
