Eye Reflex Assessment Form
Complete this assessment to evaluate various aspects of eye reflex responses. Please answer all questions based on your observations.
Patient Initials
*
Age
*
Which eye reflex is being assessed?
*
Pupillary light reflex
Corneal reflex
Accommodation reflex
Other
Pupil reaction to light
*
1
2
3
4
5
Blink response to corneal stimulation
*
Normal
Delayed
Absent
Symmetry of reflexes between eyes
*
Symmetrical
Asymmetrical
Reflex speed (response time)
*
Very slow
1
2
3
4
Very fast
5
1 is Very slow, 5 is Very fast
Observation of abnormal movements
*
Nystagmus
Photophobia
Eye deviation
No abnormal movements
Other
Assessment Matrix: Rate the following aspects for each eye
*
Rows
Left Eye
Right Eye
Direct light reflex
1
2
Consensual light reflex
3
4
Corneal reflex
5
6
Additional notes or observations
Submit Assessment
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