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, median
OR right cylinder, median
OR right axis, median
OR right confidence level reading
OR left sphere, median
OR left cylinder, median
OR left axis, median
OR left confidence level reading
Right keratometry radius flat curve (mm)
Right keratometry power flat curve (D)
Right keratometry axis flat curve (deg)
Right keratometry radius steep curve(mm)
Right keratometry power steep curve (D)
Right keratometry axis steep curve (deg)
Right keratometry radius, average (mm)
Right keratometry power, average (D)
Right keratometry cylinder
Right keratometry axis (deg)
Left keratometry radius flat curve (mm)
Left keratometry power flat curve (D)
Left keratometry axis flat curve (deg)
Left keratometry radius steep curve (mm)
Left keratometry power steep curve (D)
Left keratometry axis steep curve (deg)
Left keratometry radius, average (mm)
Left keratometry power, average (D)
Left keratometry cylinder
Left keratometry axis (deg)
Right visual acuity, presenting
Left visual acuity, presenting
Right visual acuity, w/ obj. refraction
Left visual acuity, w/ obj. refraction