DA Form 7655 at a glance
What it is: DA Form 7655 (JUN 2015) is the Armed Forces Eye and Vision Readiness Summary, which Soldiers may use to capture spectacle prescription and visual performance data (visual acuity).
Who signs: Box 10 is the doctor's signature.
A filled-in DA Form 7655 example: an eye care provider completes the summary
How to fill out DA Form 7655, box by box
Service member and unit, boxes 1 to 5
Enter the service member's name (Last, First, Middle Initial) in box 1.
Enter the date of birth in box 2 and the branch of service in box 3.
Enter the unit of assignment in box 4 and the unit address in box 5.
Doctor's dates, box 6 and spectacle Rx
To the Doctor: please complete the information under EXAMINATION RESULTS; the DOD will use the examination results on this form to determine the patient's fitness for prolonged duty without ready access to eye care, and will not use the information on this form to address or document the patient's comprehensive ocular health or visual needs.
Enter the date of vision screening (YYYYMMDD) in box 6 and the date of spectacle Rx (YYYYMMDD).
Distance and near visual acuity
For (1) uncorrected distance visual acuity and (2) best corrected distance visual acuity, fill in Right Eye 20/, Left Eye 20/ and Both Eyes 20/.
For (3) uncorrected near visual acuity and (4) best corrected near visual acuity, if > 45, fill in Both Eyes 20/.
Spectacle prescription and pupillary distance
For (5) spectacle prescription (minus cylinder format, if near vision only annotate in bifocal form), fill in the Right Eye and the Left Eye.
For each eye, fill in SPHERE, CYLINDER -, AXIS, ADDITION + and PRISM.
For (6) pupillary distance, enter FAR and NEAR in mm.
Ocular conditions, medications and refractive surgical procedures
(7) Does the patient have any ocular condition(s) that may present problems in austere environments far removed from routine medical care? YES or NO. If yes, please state condition(s).
(8) Will the patient require a 180-day supply of medication(s) to treat an ophthalmologic condition(s)? YES or NO. If yes, please provide medication(s) and dosage(s).
(9) Has the patient undergone a refractive surgical procedure(s) in the past? YES or NO. If yes, please provide month, year and type of procedure(s).
Doctor's name, license and signature, boxes 7 to 10
Enter the doctor's printed name in box 7, the state license number in box 8 and the doctor's address & telephone or e-mail address in box 9.
More rules for DA Form 7655
For use of this form, see DA Pam 40-506; the proponent agency is OTSG.
Disclosure is voluntary; however, failure to provide the information may result in delays in assessing refractive and vision health needs for military service.
Common questions about DA Form 7655
Who signs it?
Box 10 is the doctor's signature.
Sources
[1] DA Form 7655 (JUN 2015), Armed Forces Eye and Vision Readiness Summary, Department of the Army (the Official source link on this page).