Optometry Exam Forms Details

An eye examination is a process by which an optometrist or ophthalmologist determines the health of your eyes and prescribes eyeglasses or contact lenses, if necessary. During an eye examination, your optometrist will ask about any vision problems you're having and test how well you see both at distance and up close. He may also measure the curvature of your cornea and test the pressure inside your eyes. Depending on what he finds during the exam, your optometrist may also prescribe medication to help protect your eyes from disease. An eye examination is a vital part of maintaining overall eye health. If you're experiencing any vision problems, be sure to make an appointment with an optometrist as soon as possible.

You can find information about the type of form you want to complete in the table. It will tell you the span of time you will need to finish eye examination, what fields you will have to fill in, and so on.

QuestionAnswer
Form NameEye Examination
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameseye exam sheet template, optometry exam form, ophthalmology exam forms, optometry exam form pdf

Form Preview Example

MEDICAL-IN-CONFIDENCE (After first entry)

PM 529

Department of Defence

 

Revised Mar 2005

 

 

 

 

 

 

Eye Examination

 

 

 

 

 

 

 

 

 

PFID number (Recruiting use only)

 

Use only black pen and/or stamps

 

 

 

 

 

 

 

 

 

Health facility or Defence Force Recruiting Centre

 

 

Employee ID

Rank

 

 

 

 

 

Service

 

 

Family name

 

 

 

 

 

 

Unit, ship or section

 

 

Given name(s)

 

 

 

 

 

 

Corps, category or mustering

 

 

Date of birth

Gender

 

 

 

 

 

Visual acuity

 

 

 

 

Encl/Folio

Distance vision

 

 

 

 

 

 

 

 

 

 

 

 

Right

 

 

Left

Corrected

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Uncorrected

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Near vision (Corrected) (Special Forces applicants only)

 

 

 

 

 

 

 

 

Right

 

 

Left

N5 at 30-50cm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N14 at 100cm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Refractive limits with effective cycloplegia (Cyclopentolate HCL 1% is to be used)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right

 

 

Left

Hypermetropia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hypermetropic astigmatism

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Myopia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Myopic astigmatism

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Heterophoria

 

 

 

 

 

 

 

 

 

 

 

 

Right

 

 

Left

 

 

 

 

 

 

 

 

 

Exophoria

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Esophoria

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hyperphoria

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hypophoria

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

General physical examination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Normal or abnormal

 

 

Comments

 

 

Fields of vision

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diseases of the eyelid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Fundus examination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

External and anterior segment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right

 

 

Left

Intraocular pressure (mmHg)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

History of refractive surgery

 

 

 

 

 

 

 

 

 

 

 

 

 

Second appointment (Required if contact lenses worn)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Right

 

 

Left

Visual acuity wearing lenses

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Spectacle blur

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Recommended MVR

 

 

 

 

 

 

 

 

MVR 1

MVR 2

MVR 3

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

Printed name

Ophthalmologist or optometrist

 

Date

 

 

 

 

 

 

 

 

 

MEDICAL-IN-CONFIDENCE (After first entry)

PM 529 - Page 1 of 1

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