Respondent sequence number
SP has a severe eye infection?
Which eye(s) infected?
Is SP wearing an eye patch?
Which eye has eye patch?
Glasses/contact lenses for near work?
Glasses/contact lenses available?
Glasses or contacts worn for near test?
Line read on near card
Testing distance of near card
Eye surgery for near sightedness?
Which eye(s) surgery - near-sightedness?
Eye surgery for cataracts?
Which eye(s) cataract surgery?
Glasses/contact lenses worn for distance
Is distance correction available?
Which type? Glasses or contacts?
Was prescription obtained?
Prescription, right sphere
Prescription, right cylinder
Prescription, right axis
Prescription, left sphere
Prescription, left cylinder
Prescription, left axis
Visual Acuity Comments
OR right sphere, average
OR right cylinder, average
OR right axis, average
OR right confidence level reading
OR left sphere, average
OR left cylinder, average
OR left axis, average
OR left confidence level reading
Right keratometry axis, average (deg)
Left keratometry axis flat curve (deg)
Left keratometry axis, average (deg)
Right visual acuity, presenting
Left visual acuity, presenting
Right visual acuity, w/ obj. refraction
Left visual acuity, w/ obj. refraction