OPHTHOreport-AI — Intake Form

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Patient Information

Last Name

First Name

Age / DOB

Chief Complaint

Date / Record #

Date

Record #

Visual Acuity & IOP

VA SC — OD

VA CC — OD

VA SC — OI

VA CC — OI

IOP OD (mmHg)

IOP OI (mmHg)

CCT OD (µm)

CCT OI (µm)

Refraction

OD — Sph / Cyl / Axis / Add

OI — Sph / Cyl / Axis / Add

Biomicroscopy & Fundus

Biomicroscopy OD

Biomicroscopy OI

Fundus OD (C/D, macula, vessels)

Fundus OI (C/D, macula, vessels)

Diagnostic Studies Available

Clinical Notes

Report Settings