Vision Exam Results
Name
*
First Name
Last Name
Email
example@example.com
Company
Please Select
Capstone Michelin
OHS
Corrective Lenses:
*
Please Select
No
Yes
Far Vision- Better Eye:
*
Please Select
20/10
20/13
20/15
20/20
20/25
*20/30
*20/40
*20/50
*20/70
*20/100
*20/200
Far Vision- Other Eye:
*
Please Select
20/10
20/13
20/15
20/20
20/25
20/30
20/40
20/50
*20/70
*20/100
*20/200
Near Vision- Both Eyes:
*
Please Select
20/10
20/13
20/15
20/20
20/25
20/30
20/40
20/50
*20/70
*20/100
*20/200
Binocularity:
*
Please Select
Normal
Abnormal
Stereo Acuity:
*
Please Select
40 Secs of Arc
50 Secs of Arc
60 Secs of Arc
80 Secs of Arc
100 Secs of Arc
*140 Secs of Arc
*200 Secs of Arc
*400 Secs of Arc
*800 Secs of Arc
Color Vision:
*
Please Select
Normal
Abnormal
Distinguish Green, Amber & Green:
Please Select
No
Yes
Horizontal Visual Field:
Please Select
170-180 degrees
150-169 degrees
90- 149 degrees
60- 89 degrees
0- 59 degrees
Vertical Visual Field:
Please Select
80- 90 degrees
70- 79 degrees
30- 69 degrees
0-29 degrees
Passed Test
*
Please Select
Passed
Failed
Restricted to Corrective Lenses
*
Please Select
No
Yes
Test Administered By:
*
Please Select
Bettina Hendrix
Ja'Near Allen
Nina Raddatz
Skyler Raddatz
Signature of Examiner
*
Signature of {name}
*
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