Optometry Comprehensive Eye & Vision Examination Note (Adult)

Date/Time: [Date and time of encounter]

Encounter Type: [new / established]; [comprehensive / problem-focused]; [vision / medical / combined]

Clinician: [Clinician name and credentials]

History Source: [patient / family or caregiver / interpreter] (If interpreter used, include language and modality.)

Chief Complaint / Reason for Visit

[Patient-stated primary reason for visit] (Use a concise, patient-centered statement. Include primary goal and secondary concerns when present. Use direct quote when helpful.)

History of Present Illness

[Narrative of presenting concern(s)] (For symptomatic visits include onset, duration, laterality [OD/OS/OU], severity, triggers/relievers, associated symptoms [pain, redness, photophobia, flashes, floaters, diplopia, halos, headaches], functional impact, and prior treatments with response. For asymptomatic routine exams, briefly state absence of visual symptoms and exam intent.)

Visual Needs

[Primary visual tasks and demands: distance/driving, near/reading, intermediate/computer, occupational requirements, hobbies; note prior eyewear performance issues if relevant]

Ocular History

• Past Ocular Diagnoses: [Diagnoses with laterality (OD/OS/OU) and status]
• Surgeries/Procedures/Trauma: [Procedure or trauma with laterality and date]
• Current Ocular Medications: [Medication, eye, dose, frequency]
• Last Eye Exam: [Date and location if known]
• Current Glasses: [Prescription age, usage, adaptation issues]
• Contact Lens History: [Lens type/material, wear schedule, replacement schedule, compliance concerns] (Include only if contact lens wearer.)

Medical History

[Systemic conditions with ocular relevance and control status; include diabetes type/duration/recent A1c, hypertension, thyroid disease, autoimmune conditions, neurologic conditions, sleep apnea as applicable]

Medications & Allergies

Systemic Medications: [List with dose and frequency when known]

Ocular Medications: [Medication, eye, dose, frequency]

Allergies: [Drug allergies with reaction type; document NKDA if none]

Family Ocular History

[Hereditary conditions with relationship: glaucoma, macular degeneration, retinal detachment, keratoconus, high myopia] (Include relationship: parent/sibling.)

Social History

[Tobacco use status; occupation with relevant exposures (UV, chemicals, impact hazards); driving status; eye protection practices; falls risk if vision-related concerns in older adults]

Visual Acuity & Refraction

Chart Type: [Snellen / ETDRS]

Test	OD	OS	OU
Distance VA uncorrected (sc)	[VA OD]	[VA OS]	[VA OU]
Distance VA with current correction (cc)	[VA OD]	[VA OS]	[VA OU]
Pinhole VA	[VA OD]	[VA OS]	[—]
Near VA (with appropriate correction)	[VA OD]	[VA OS]	[VA OU]

Manifest Refraction

Parameter	OD	OS
Sphere (D)	[Sphere OD]	[Sphere OS]
Cylinder (D)	[Cylinder OD]	[Cylinder OS]
Axis (°)	[Axis OD]	[Axis OS]
Best Corrected VA	[BCVA OD]	[BCVA OS]
Add (D)	[Add OD]	[Add OS]

Cycloplegic Refraction: [Indication and findings] (Include only if performed.)

Final Spectacle Prescription:

Parameter	OD	OS
Sphere (D)	[Sphere OD]	[Sphere OS]
Cylinder (D)	[Cylinder OD]	[Cylinder OS]
Axis (°)	[Axis OD]	[Axis OS]
Add (D)	[Add OD]	[Add OS]
Prism / Base	[Prism OD / base]	[Prism OS / base]
PD / Seg Ht	[PD OD / Seg Ht]	[PD OS / Seg Ht]

[Lens recommendations and special instructions] (Include if provided.)

Binocular Vision Testing

(Include only if performed.)

• Indication: [Reason for testing]
• Cover Test: [Distance and near findings with magnitude/direction]
• Vergences: [Ranges at distance and near]
• NPC: [Break/recovery in cm]
• Accommodation: [Amplitude/facility if assessed]
• Stereoacuity: [Result if tested]

Contact Lens Evaluation

(Include only if contact lens evaluation was performed.)

• Current Lens: [Brand/material, base curve, diameter, power (D)]
• Fit Assessment: [Centration, movement, coverage, fluorescein pattern if RGP]
• Over-refraction: [Findings and resulting VA]
• Wear/Compliance: [Wear time today, average daily wear, replacement adherence, care system]
• Comfort: [Comfort rating, end-of-day symptoms]
• Final Contact Lens Rx: [Brand/material, base curve, diameter, power (D), cylinder/axis if toric, add if multifocal]

Ocular Health Examination

• Pupils: OD [size, reactivity]; OS [size, reactivity]; RAPD [present / absent]
• Extraocular Motility: [Versions, alignment; note diplopia if present]
• Confrontation Visual Fields: OD [result]; OS [result] (Note if formal perimetry indicated.)
• Intraocular Pressure: [Method] at [time] — OD: [value] mmHg; OS: [value] mmHg
• Anterior Segment:
  • Lids/Lashes: [Findings]
  • Conjunctiva/Sclera: [Findings]
  • Cornea: [Findings with grading if significant]
  • Anterior Chamber: [Depth, cell/flare]
  • Iris: [Findings]
  • Lens: [Findings; cataract grade if present]
  • Angles: [Method and grade] (Include if narrow angle concern.)
• Dilation Status: [Dilated exam performed / Dilated exam not performed]
  • (If performed: agent(s) used, time instilled, adequate dilation achieved [yes/no], adverse reaction [none / describe].)
  • (If not performed: reason [patient declined / contraindication / narrow angles / deferred for driving or work / other] and plan for alternative evaluation or follow-up.)
• Posterior Segment: Examined via [BIO / 90D lens / 78D lens / undilated fundus view]
  • Vitreous: [Findings]
  • Optic Nerve: OD C/D [ratio]; OS C/D [ratio]; [rim appearance, RNFL, disc hemorrhages, edema]
  • Macula: [Findings]
  • Vessels: [Findings]
  • Periphery: [Findings; extent of view]

Ancillary Testing

(Include only if testing was performed or ordered this encounter.)

• [Test name]: Indication: [reason]; Findings: [key results]; Interpretation: [clinical meaning]; Management impact: [how results affect plan / no change in management]

Assessment

(Problem-list format by clinical priority. For each diagnosis include laterality, severity/stage when relevant, and status. Label suspected conditions as "suspect" or "rule out" with diagnostic plan.)

1. [Diagnosis with laterality (OD/OS/OU), severity/stage, status (new/known; stable/progressing/improved)]
2. [Additional diagnoses as applicable]

Plan

(Numbered by problem, matching Assessment order.)

1. [Problem 1]:
   • Treatment: [Optical Rx with lens recommendations; medications with drug, concentration, eye, dose, frequency, duration; non-pharmacologic interventions]
   • Testing: [Diagnostic testing ordered with indication]
   • Referrals: [Subspecialty, PCP, low vision services as indicated]
   • Counseling: [Diagnosis explanation, prognosis, risk modification provided]
   • Return Precautions: [Urgent symptoms to monitor: flashes/floaters, curtain/shadow, acute vision loss, pain]
   • Follow-up: [Interval specific to this problem]
2. [Problem 2]:
   • Treatment: [Management actions]
   • Testing: [If indicated]
   • Referrals: [If indicated]
   • Counseling: [Education provided]
   • Return Precautions: [If applicable]
   • Follow-up: [Interval]

Consolidated Follow-up: [Next visit timeframe and purpose; if multiple intervals, specify earliest and note others]

Procedures Performed

(Include only if same-day procedures were performed.)

• [Procedure name]: Indication: [reason]; Consent: [obtained]; Site: [laterality]; Technique: [method]; Outcome: [result]; Complications: [none / describe]; Post-procedure instructions: [given]; Follow-up: [plan]

(Document only elements actually examined or assessed—do not infer normal findings for tests not performed. If clinically important information is unavailable, note as unknown with plan to obtain. Document patient-reported diagnoses without records as "patient-reported history." Omit non-applicable sections entirely.)