Cycloplegic Eye Exam Record Form
Please complete all sections to accurately document the cycloplegic eye examination.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Patient Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Exam Date
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Reason for Examination
*
Cycloplegic Medication Used
*
Cyclopentolate
Tropicamide
Atropine
Other
Pre-Dilation Visual Acuity (OD/OS)
Post-Dilation Visual Acuity (OD/OS)
Cycloplegic Refraction Results
*
Exam Findings and Notes
*
Examiner Name
*
First Name
Last Name
Signature of Patient or Guardian
*
Submit Exam Record
Submit Exam Record
Should be Empty: