Name__________________ Occupation__________________ Age_____ D.O.B.___/___/___ Date___/___/20___

Address_________________ City/State_______________ Phone (home/work/cell)__________ Email_____________

VAs 1

Far (no Rx)

Far (w/ Rx)

Near (no Rx)

Near (w/ Rx)

Old

Rx Sph. Cyl. Axis Add Prism OCs

Lens

Tint

Lens

Type

OD 20/ 20/ 20/ 20/

Right . . ° + . Δ

/

OS 20/ 20/ 20/ 20/

Left . . ° + . Δ

/

OU 20/ 20/ 20/ 20/

IPD / Other Information:

2

R

/ @

Problems/Complaints: (ٱ routine exam)

L

/ @

3 Δ 13A Δ

4

R . – . × ° 20/ General Health: (ٱ good)

20/

L . – . × ° 20/

Medications: (ٱ none)

5 R + . (dynamic add over #4 @ 20") L + . (dynamic add over #4 @ 20")

7

R . – . × ° 20/ Medical Allergies: (ٱ none)

20/

L . – . × ° 20/ Eye History: (ٱ n.p.)

8 Δ 9 / Family History: (ٱ n.p.) diabetes_____________ hypertension_____________ cancer_____________

10 / 11 / glaucoma_____________ cataracts_____________ armd_____________ other_________________

12A,B Δ R R sup / R inf / ___________________________________________________________________________________

13B Δ [– Δ / +1.00D gradient] Right Anterior Left

14A R + . add

15A Δ Lids/Adnexa Pupils (ٱ PERRLA) Lids/Adnexa

L + . add Cornea Iris Lens Cornea Iris Lens

14B + . add 15B Δ

16 / / / 17 / / /

18A,B Δ R R sup / R inf /

19 ____in. or ____cm. ( . D) Right Posterior Left

20 + . D 21 – . D A/V: / Fundus

C/D: . V / . H

A/V: / Fundus

C/D: . V / . H

Tono: ____________

R ______ mm Hg

L ______ mm Hg

Anes.: ____________ Time: ____________

Cover Test (___unaided ___#7 ___present Rx): Analysis:

PR Δ PP Δ Pursuits: Saccades: Stereopsis: " of arc other: test: _____________________________________ Plan:

Color Perception: test: _____________________________________

Worth 4-Dot: _____red _____green _____white

Return:_____________

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