Optometry Myopia Management Visit Note

Date/Time: [Date and time]

Location: [Clinic/location]

Provider: [Provider name, credentials]

Patient: [Patient full name]

Age: [Age]

Visit Type: [Initial Evaluation / Follow-up]

Guardian Present: [Name, relationship / Not applicable — adult patient] (Required for minors. If guardian not present for a minor, document circumstance and how consent was obtained.)

History Obtained From: [Patient / Parent-Guardian / Both / Other source]

Chief Complaint

[Brief reason for visit, using patient/parent wording in quotes when available] (If not provided, use a minimal statement such as "Myopia management follow-up.")

History

[For initial evaluations: Narrative including age at myopia onset, earliest known prescription, current symptoms (distance blur, strain, squinting), functional impact (school, sports), prior myopia control attempts and tolerance. For follow-ups: Interval changes since last visit including vision changes, treatment adherence with specific frequency, side effects experienced, and relevant lifestyle changes.]

Current Optical Correction: [Type and key parameters] (Distinguish from control modality.)

Current Myopia Control Modality: [None / Spectacle-based / Soft multifocal CL / Ortho-k / Pharmacologic / Combination] — [Start date] — [Key parameters]

Myopia Progression Risk Summary: [Age at onset] | [Parental myopia history] | [Prior progression rate] | [Outdoor time estimate] | [Near work patterns] — Overall risk: [low / moderate / high] with [brief rationale] (State "unknown" for any unavailable element rather than omitting.)

Objective

• Vision: [Distance VA per eye; specify corrected vs uncorrected as relevant]
• Refraction: [Manifest refraction] — Cycloplegic: [performed with agent and findings / not performed with reason and plan]
• Axial Length: [OD: value; OS: value / Not measured — reason and plan]
• Anterior/Posterior Segment: [Key findings] — [Dilated / Not dilated with reason and plan]
• Contact Lens Findings: [Fit assessment; corneal health; compliance observations] (Include if applicable.)
• Progression Tracking: SER change: [value, dates compared]; Axial length change: [value, dates compared]; [Annualized rate if sufficient interval]

Assessment

• Myopia: [low / moderate / high] severity — [stable / controlled / progressing / rapidly progressing] — [Brief interpretation referencing objective data]
• [Other clinically significant diagnoses] (Include only when present: astigmatism, binocular vision issues, contact lens complications, etc.)

Plan

• Treatment: [Chosen modality and parameters] — Rationale: [efficacy goals, lifestyle fit, patient preference, cost considerations]
• Pharmacologic Details: [Medication, concentration, dosing schedule, off-label status, compounding source] (Include if applicable.)
• Contact Lens/Ortho-k Counseling: [Hygiene instructions reviewed; wear schedule; discontinuation criteria reviewed] (Include if applicable.)
• Shared Decision-Making: Discussed [alternatives considered]; reviewed risks, benefits, and uncertainties; questions answered; [patient / guardian] agrees with plan
• Lifestyle Counseling: [Outdoor time targets]; [near work and break recommendations]
• Follow-up: [Interval and purpose; tests planned] (For CL/ortho-k: Return precautions reviewed — discontinue wear and seek care for pain, redness, photophobia, discharge, or vision decrease. For high myopia: Retinal warning signs reviewed — flashes, floaters, curtain/shadow in vision.)
• Orders: [Prescriptions, imaging, testing, referrals] (Include if applicable.)

Signature/Credentials: [Provider name, degree, license] [Date/time signed]