Academy of Our Lady
180 Rodney Street
Glen Rock, NJ 07452
Student:
Address:
EYE DOCTOR REPORT
| VISUAL ACUITY | RIGHT EYE | LEFT EYE | BOTH EYES |
| WITHOUT CORRECTION | 20/ | 20/ | 20/ |
| WITH CORRECTION | 20/ | 20/ | 20/ |
| DIAGNOSIS | |||
| REFRACTIVE ERROR | HYPEROPIA | MYOPIA | ASTIGMATISM |
| OD______OS______ | OD______OS_______ | OD_______OS________ | |
| MUSCLE IMBALANCE | |||
| TROPIA OS____ OD_______ TYPE_____________________ | |||
| PHORIA OS____ OD_______ TYPE_____________________ | |||
| AMBLYOPIA | |||
| PRESENT OS_____ OD______ | |||
| OTHER DIAGNOSIS | |||
| SPECIFY:_____________________________________________________________________________________ | |||
| RECOMMENDATIONS: | |||
| Were glasses prescribed?_________________________________________________________________________ | |||
| Are glasses to be worn for sports?__________________________________________________________________ | |||
| What treatment, if any, was recommended?__________________________________________________________ | |||
| When do you wish to see this student again?_________________________________________________________ | |||
| Additional comments____________________________________________________________________________ | |||
| Date of exam:_____________________________ | |||
|
OFFICE STAMP |
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| Printed name:_____________________________ | |||
| _________________________________________ | |||
| Doctor's Signature | |||