Author: Paul Harris

NAME __________________________________________ DATE ___________ DOB___________ Gender___ CODE __________
REFERRED BY _______________________________________________ OCCUPATION ________________________________
HISTORY:
DV LVE WHERE/WHOM
NV 1st Rx
HA CL's H/S/G D/EW/DISP/MONO-V SOL:
DBL PMEH
LIKE Allergies
DISLIKE
BEST Fam/Health
WORST
READ
SPELL Gen/Health
WRITE
FREETIME Meds.

VISUAL ACUITY WD ______ POSTURE ________________
DV NO Rx DV W RX NV NO Rx NV W Rx DV Pin KERATOMETRY
OD _________ _________ _________ _________ _________ OD ___________ __________ X ______
OS _________ _________ _________ _________ _________ OS ___________ __________ X ______
OU _________ _________ _________ _________ _________ Keystone Basic Binocular Suppression Y / N
COVER DISTANCE COVER NEAR Localize Y / N Depth Y / N / Gross Only
_______________________ ___________________ PUPILS PERRLA Y/N MARCUS-GUNN Y/N
___________________________________________
Motilities TONOMETRY TIME ___________ TYPE __________
HD S / M / L /ALL BODY S/M/L LIMITS __________ OD ______ mm/HG OS ______ mm/HG
ACCURACY Ex / G / F / P ________________________ SLIT LAMP
CNP RGR
_______________________ ___________________ ___________________________________________
WORTH 4 DOT DV NV +/-2.00 INTERNAL
_________________ _____________ ___________
COLOR RANDOT/STEREO
_________________ _________________________
STRESS POINT RETINOSCOPY
___________________________________________ ____________________________________________
CL FIT EXTERNAL

Analytical
RET
4 OD _________________________________
OS _________________________________
SUBJECTIVE (Binoc Most+ Least-)
7 OD _________________________________ OD 20/____
OS _________________________________ OS 20/____
OU 20/____
SUBJECTIVE (Largest)
7A OD _________________________________ OD 20/___
OS _________________________________ OS 20/___
OU 20/___
DIST PHORIA 8 Through 7/7A
8 _____________________________
3 _____________________________
DV CONTROL: 7 7A PLANO CL's Hab _______
DISTANCE EQUILIBRIUM (9/10/11)
NEAR PHORIA
13A____________________ 13B ____________________
UNFUSED CROSS CYLINDER
14A OD _____________________________ A G
OS _____________________________ A G
FUSED CROSS CYLINDER
14B OD _____________________________ A G
OS _____________________________ A G
PHORIA With 14B
15B ________________________
NV CONTROL: 14B 7 7A PLANO CL's Hab _______
NEAR EQUILIBRIUM (16/17)
PRA/NRA
21 _______________________________ A G
20 _______________________________ A G
VERTICAL PHORIA RANGE
12 ________________ / ___________ R L S I
18 ________________ / ___________ R L S I
CL OVER REFRACTION
OD _________________ OS __________________

5 10 15 20 25

Out

In

25 20 15 10 5

5 10 15 20 25

Out

In

25 20 15 10 5

HAB RX OD ___________________________________
OS ___________________________________
ALTERNATIVES OF CARE:
1. COMPENSATORY LENS ONLY OR NO TREATMENT
Rx OD___________________________ Add _________
OS___________________________ Add _________
PROGNOSIS:
_____________________________________________
2. LENS TREATMENT ALTERNATIVE
Rx OD ___________________________ Add ________
OS ___________________________ Add ________
PROGNOSIS:
_____________________________________________
3. LENS TREATMENT WITH VISION THERAPY
Rx OD ___________________________ Add _________
OS ___________________________ Add _________
PROGNOSIS:
DATE ________ FINAL PRESCRIPTION PD___/_____
OD ______________________ ADD _______ PRISM ____
OS ______________________ ADD _______ PRISM ____
SEG TYPE _______________ LENS TYPE ______________
SEG PLACEMENT _____________ TINTING ____________
FRAME NAME_________________ FRAME SIZE ________
FRAME COLOR _______________ TEMPLE TYPE ________
TEMPLE LENGTH ______________INVENTORY # _______
GLASSES USE: All the time NV only DV only
Occupationally As needed

Analytical
RET
4 OD _________________________________
OS _________________________________
SUBJECTIVE (Binoc Most+ Least-)
7 OD _________________________________ OD 20/____
OS _________________________________ OS 20/____
OU 20/____
SUBJECTIVE (Largest)
7A OD _________________________________ OD 20/___
OS _________________________________ OS 20/___
OU 20/___
DIST PHORIA 8 Through 7/7A
8 _____________________________
3 _____________________________
DV CONTROL: 7 7A PLANO CL's Hab _______
DISTANCE EQUILIBRIUM (9/10/11)
NEAR PHORIA
13A____________________ 13B ____________________
UNFUSED CROSS CYLINDER
14A OD _____________________________ A G
OS _____________________________ A G
FUSED CROSS CYLINDER
14B OD _____________________________ A G
OS _____________________________ A G
PHORIA With 14B
15B ________________________
NV CONTROL: 14B 7 7A PLANO CL's Hab _______
NEAR EQUILIBRIUM (16/17)
PRA/NRA
21 _______________________________ A G
20 _______________________________ A G
VERTICAL PHORIA RANGE
12 ________________ / ___________ R L S I
18 ________________ / ___________ R L S I
CL OVER REFRACTION
OD _________________ OS __________________

5 10 15 20 25

Out

In

25 20 15 10 5

5 10 15 20 25

Out

In

25 20 15 10 5

HAB RX OD ___________________________________
OS ___________________________________
ALTERNATIVES OF CARE:
1. COMPENSATORY LENS ONLY OR NO TREATMENT
Rx OD___________________________ Add _________
OS___________________________ Add _________
PROGNOSIS:
_____________________________________________
2. LENS TREATMENT ALTERNATIVE
Rx OD ___________________________ Add ________
OS ___________________________ Add ________
PROGNOSIS:
_____________________________________________
3. LENS TREATMENT WITH VISION THERAPY
Rx OD ___________________________ Add _________
OS ___________________________ Add _________
PROGNOSIS: