• Ocular Health Assessment Form

  • Do you currently have sore throat, fever, fatigue, loss of smell, or respiratory symptoms?*
  • Have you tested positive for COVID-19, or been in the presence of someone with known COVID-19 in the last 2-14 days?*
  • Chief Complaint*




  • Manifest/Final Spectacle Rx
    OD x   
    OS x 
    ADD   

  • Additional Spectacle Rx
    OD x   
    OS x 
    ADD   

  • Contact Lens Rx   
       
    OD x   
    OS x 
    Other:      









  • Optic Nerve Head*

  • Dilation:*
  • Macula*





  • Clear
  • Should be Empty: