Faculty of Science
Appendix XIII – Laser Operator Examination Form
This page must be signed and approved by the patient’s supervisor and the Faculty of Science financial representative before a medical eye examination can be conducted.
Patient Details
Name: / DOB:Department: / Sex:
Position: / Phone:
ID Number: / Email:
______
Patient’s Supervisor Date
(Print and Sign)
______
Faculty Representative Date
(Print and Sign)
Eye Examination to be completed by an Optometrist
Optometrist Location/Address: OPSM North Ryde
Level 2 – Ref. F23
Macquarie Shopping Centre, Herring Rd
North Ryde NSW 2113 (9878 4377)
Yes / No1. Ocular History Normal?
If No, describe: / □ / □
2. General Health Normal?
If No, describe: / □ / □
3. Any photosensitising drug medications?
If Yes, describe: / □ / □
4. Visual Acuity (with spectacles if worn)
Write denominator of Snellen fraction:
(e.g. 60 if visual acuity is 6/60) / □ / □
5. Amsler grid normal?
If No, describe: / □ / □
6. Colour Vision (Farnsworth D15 test) normal?
If No, describe: / □ / □
7. Refraction (only use if visual acuity in item 3 is less than 6/6)
Visual acuity (Snellen denominator)
Refractions R L
8. External Ocular examination normal?
If No, describe: / □ / □
9. / (Tick if abnormal)
Slit Lamp / RE / LE / Describe any abnormality
Cornea / □ / □
Aqueous / □ / □
Iris & Pupil / □ / □
Van Herick a/c / □ / □
Lens (Depth of Opacities) / (draw extent & depth of opacities)
Subcapsular / □ / □ /
Anterior cortex / □ / □
Mid nuclear / □ / □
Posterior nuclear / □ / □
Posterior cortical / □ / □
Post subcapsular / □ / □
Capsular or extracapsular opacities / □ / □
Lens (Types of Opacities)
Epicapsular stars, pigment spots / □ / □
PXF / □ / □
Cortical wedges or spokes / □ / □
Cortical clubs / □ / □ / (position of opacities)
Cortical dots / □ / □
Cortical flakes / □ / □
Central fluid clefts and vacuoles / □ / □
Cortical Plaques / □ / □
Posterior saucer / □ / □
Posterior rosette / □ / □
Polychromatic lustre / □ / □
Diffuse nuclear sclerosis / □ / □
Nuclear wedges / □ / □
Sutural opacities / □ / □
Nuclear needles / □ / □
Nuclear flakes / □ / □
Other / □ / □
Yes / No
10. Ophthalmoscopy normal?
If No, describe:
Photograph if necessary / □ / □
11. Other examinations
12. Summary and Comment
______
Optometrist: Date
(Print and Sign)
______
Patient Date
(Print and Sign)
NB: The current fee (1/1/10) is $90 and includes photographs of the patient’s retinas.
As of 1/1/2015, OPSM will invoice the University directly.
Please return your exam report to Dr Susan Law (x8126, E7B-251)
31st August 2015 Page 1 of 4