PATIENT RECORD CARD EXAMINER: _______________________ID:_______________

Notes/Observations: Name:
Address:
Postal code: City:
Tel. Home: Work:
Place of birth: Date of birth:
General practitioner: Place:
Occupation: Date:

Age, Race, Gender: Reason for visit

Personal Ocular History (Refractive): Ocular Symptoms :

None:

Personal Ocular History (Health): Personal General Health History (Past and present):

Date of last eye exam: Date of last medical exam:

Who/Where: Who/Where:

Family Ocular History: General Family History (Past and present):

Medication, dosage, frequency, condition: Allergies (Medicine, General):

PATIENT RECORD CARD

PD (mm) (D/N)

VA (-) Rx (+) Rx PH (+)Rx CL CL Status (SLE)

Distance Near Distance Near Distance Distance Near
OD OD OD
OS OS OS
OU OU __________ OU

SUPERVISOR: ________________________