Amsler Grid Eye Test

Patient’s Name: ________________________________________________________________

Reference Record #: ____________________________________________________________

Tel: (home) ________________________

(Mobile) ___________________________________

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Date of Birth: ____________________________

Gender:

Male

Female

Stare at the black dot at the center of the grid with one eye. Repeat with the other eye:

•

Are you able to see the corners and sides of the square? Yes / No ________________

•

Do you see any wavy lines? Yes / No ________________

•

Are there any holes or missing areas? Yes / No ________________

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Parent category: Medical