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Brief Vision Exam

BRIEF VISION EXAM

Name:                                                              Age:                 Date:                                               

Va       cc                                 Vnear  cc          W                           x               Add               

 

sc                                             sc                                          x                                    

M                                                         x                                             Add                             

                                     x                                                                                

T                                 

           

Impression:      Refractive error

Normal exam

Other:                                                                                                             

Plan:                Rx = M

No Rx

Follow-up for additional ophthalmology evaluation

 

                                                            , M.D.

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