Eye Exam Form

Digitizes the clinical record of every vision check: aided and unaided visual acuity, refraction, diagnosis, and lens recommendations. The optometrist signs on screen and the record is stored instantly.

Use this template

Patient Name

Nombre

Apellido

Date of Exam

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 Refraction not performed

Corrective Lenses

Recommended Not needed Update existing prescription

If yes, glasses should be worn for:

Distance Near and reading Screen use Full-time wear

Preferential seating recommended

Yes No To be evaluated

Recommend re-examination in

6 months 12 months 24 months As needed

Optometrist / Physician's Name

Nombre

Apellido

Email

Phone Number

Address

Dirección

Ciudad

Estado / Provincia

Código postal

Signature

Sign here

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