Eye Exam Form Template
Patient Name
First Name
Last Name
Date of Exam
-
Month
-
Day
Year
Date
Case History
Rows
Normal
Other
Ocular History
1
Medical History
2
Drug Allergies
3
Examination
Unaided Visual Acuity (20/) - Distance / Right
Unaided Visual Acuity (20/) - Distance / Left
Unaided Visual Acuity (20/) - Distance / Both
Unaided Visual Acuity (20/) - Near / Both
Best Corrected Visual Acuity (20/) - Distance / Right
Best Corrected Visual Acuity (20/) - Distance / Left
Best Corrected Visual Acuity (20/) - Distance / Both
Best Corrected Visual Acuity (20/) - Near / Both
Was refraction performed with cycloplegic agents?
Yes
No
4
Rows
Normal
Abnormal
Not Able to Assess
External Exam (eye and adnexa)
5
6
7
Internal (media, lens, fundus, etc.)
8
9
10
Accommodation and Vergence
11
12
13
Neurological Integrity (pupils)
14
15
16
Color Vision
17
18
19
IOP (glaucoma)
20
21
22
Oculomotor assessment
23
24
25
Diagnosis
Normal
Myopia
Hyperopia
Astigmatism
Strabismus
Amblyopia
Recommendations
Corrective Lenses
Yes
No
If Yes, glasses should be worn for:
Constant Wear
Near Vision
Far Vision
May be removed for physical activities
Preferential seating recommended
Yes
No
Recommend re-examination
3 months
6 months
12 months
Other
Optometrist / Physician's Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
Submit
Should be Empty: