Used by optometrists to record results of eye exams and visual acuity tests.
Purpose: This report documents the findings of a comprehensive vision examination, including patient details, visual acuity measurements, and any additional notes or recommendations made by the optometrist.
Full Name | Date of Birth | Gender | Examination Date |
---|---|---|---|
{fullName} | {dateOfBirth} | {gender} | {examDate} |
Eye | Unaided Vision | Corrected Vision | Lens Prescription |
---|---|---|---|
{#visionTests}{eye} | {unaidedVision} | {correctedVision} | {lensPrescription}{/visionTests} |
Test Used: {colorVisionTest}
Result: {colorVisionResult}
Left Eye: {peripheralLeft}
Right Eye: {peripheralRight}
{otherObservations}
{recommendations}
{#additionalTests}
{/additionalTests}
Optometrist Name | Registration No. | Signature |
---|---|---|
{optometristName} | {registrationNumber} | {signature} |
Date of Report: {reportDate}
{#requiresFollowUp}Note: A follow-up examination is recommended on {followUpDate}.{/requiresFollowUp}
{^requiresFollowUp}Note: No follow-up examination is necessary at this time.{/requiresFollowUp}
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