Vision Exam

Form Approved

OMB No.0920-XXXX

Exp. Date xx/xx/20xx

Vision Exam
Participant ID		_______________________
Name of Assessor		__________________(free type)
Name of Data Clerk		__________________(free type)
Date of assessment		______ (day – 2 digits) ______ (month – 2 digits) __________ (year – 4 digits)
External Exam	 Normal  Normal		Abnormal (please specify): __________________(free type) Abnormal (please specify): __________________(free type)
Assessment of Fixation
Ocular Motility Assessment	 Normal		Abnormal (please specify): __________________(free type)
Visual Fields	 Normal		Abnormal (please specify): __________________(free type)
Pupil Exam	 Normal		Abnormal (please specify): __________________(free type)
Dilated Eye Exam	 Normal		Abnormal (please specify): __________________(free type)
Refraction	 Normal		Abnormal (please specify): __________________(free type)
Indirect Ophthalmoscopy of Retina and Optic Nerve (i.e. Fundus Exam)	 Normal		Abnormal (please specify): __________________(free type)
If Applicable:
Other Exam __________________ [Exam Type – free type]	 Normal		Abnormal (please specify): __________________(free type)
Other Exam __________________ [Exam Type – free type]	 Normal		Abnormal (please specify): __________________(free type)