Visual Examination Form - Best Friends Community Services printable pdf download

Visual Examination Form - Best Friends Community Services

Visual Examination

Name: _________________________________________________ Date: _________________

Date of Birth: _________________________________ Examiner: _______________________

VISUAL ACUITY

A. HOTV Chart

B. Snellen Chart

C. E Chart

II.

VISUAL FIELD

A. Right Eye without Corrective Lenses: _____________________________________

B. Left Eye without Corrective Lenses: ______________________________________

C. Right Eye with Corrective Lenses: ________________________________________

D. Left Eye with Corrective Lenses: _________________________________________

III.

EXTERNAL EXAM

A. Condition of Eyelids: __________________________________________________

B. Condition of Conjunctiva: ______________________________________________

C. Condition of Iris: _____________________________________________________

D. Condition of Cornea: __________________________________________________

IV.

PULPILLARY EXAM

A. Size: _______________________________________________________________

B. Shape: _____________________________________________________________

C. Reaction to Light: _____________________________________________________

Direct Reaction: ______________________________________________________

Consensual Reaction: _________________________________________________

If an accurate acuity cannot be determined, please describe observed responses used in

Determining functional vision.

Confidential Information

Visual Examination Form - Best Friends Community Services