Tabela man1 OD fc n,nn OD cc n,nn cu +/- nn,nn sfera +/- nn,nn cil./ nnn (OD1) (OD2) (OD3) (OD4) (OD5) (X)A.V. A.V. OS fc n,nn OS cc n,nn cu +/- nn,nn sfera +/- nn,nn cil. / nnn (OS1) (OS2) (OS3) (OS4) (OS5) Tabela man2(X)VB prezenta/absenta Stereo +/- text 2 randuri

(VB1) (VB2)

Tabela man3(X)Simt cromatic: normal text 5 r. Sc1Tabela man4 OD +/- nn,nn DSf. +/- nn,nn Dcil., Ax nnn

Od1 od2 od3

(X)AutorefractometrieFara picaturi / cu Cyclopentolat / cu Tropicamida

Ar1

OS +/- nn,nn DSf. +/- nn,nn Dcil., Ax nnn

Os1 os2 os3

Tabela man5

OD +/- nn,nn DSf. +/- nn,nn Dcil., Ax nnn

OD1 OD2

OD3

(X)SchiascopieFara picaturi / cu Cyclopentolat / cu Tropicamida

SC1

OS +/- nn,nn DSf. +/- nn,nn Dcil., Ax nnn

OS1 OS2

OS3

Tabela man6(X)TOD : nn mmHg tod1 TOS : nn mmHg tos1 TOD ajustata : nn mmHg tod2 TOS ajustata: nn mmHg tos2 Pahimetrie OD: nnn m tod3

Pahimetrie OS: nnn m tos3Tabela man7(X)Biomicroscopie OD: pol anterior normal /Conjunctiva aspect normal text 5 randuri od2

Od1

Cornee aspect normal text 5 randuri od3

Cristalin aspect normal text 5 randuri od4

Iris aspect normal text 5 randuri od5

Pupila aspect normal text 5 randuri od6

Camera ant. aspect normal text 5 randuri od7 Biomicroscopie OS: pol anterior normal/ Conjunctiva aspect normal text 5 randuri os2

Os1

Cornee aspect normal text 5 randuri os3

Cristalin aspect normal text 5 randuri os4

Iris aspect normal text 5 randuri os5

Pupila aspect normal text 5 randuri os6

Camera ant. aspect normal text 5 randuri os7Tabela man8(X) Test Schirmer OD normal/nn mm

OS normal/nn mm

od1

os1Tabela man9(X)Oftalmoscopie indirecta: of1Tabela man10(X)F.O. OD:

Papila aspect normal text 5 randuri od1

Vase aspect normal od2

Macula aspect normal od3

Periferie aspect normal od4

Vitros aspect normal od5 F.O. OS:

Papila aspect normal os1

Vase aspect normal os2

Macula aspect normal os3

Periferie aspect normal os4

Vitros aspect normal os5Tabela man11 ????(X)Cover test/Krimpsky AO/OD/OS Ortoforie/Esotropie/ExotropieCover test cu prisme la distana +/- nn ODF/OSF/AOF cc/fc ; la aproape: +/- nn ODF/OSF/AOF cc/fcText 1 randTabela man12(X)Compensare prismatic OD: nn DPB Nazal/Temporal/Superior/Inferior si OS: nn DPB Nazal/Temporal/Superior/InferiorText 2 randTabela man13(X)Motilitate OD : Normala Text 3 rand od1 Motilitate OS : Normala Text 3 rand os1Tabela man14 ???(X) BIOMETRIE: OD: K1K2AxAP D IOL Refr

OS: K1K2AxAP D IOL Refr

Tabela man15(X)Ecografie: text 30 rand tod1Tabela man16(X)Camp vizual computerizat atasat text 30 rand tod1Tabela man17(X)ERG/EOG/PEV atasat text 30 rand tod1DIAGNOSTIC: (campurile de mai jos sunt deja definite in tabela consultations)1 text selectabil, modificabil -2 randuri23

4

5Obs. Text 10 rand(X)Rp/ 1 text selectabil, modificabil, salvabil -2 randuri

2

3

4Control peste nn zile/luni/ani .Data.....................

Dr. ..................................

(X)

ODOS

SferaCilindruAxPrismaSferaCilindruAxPrismaDP(mm)

DISTAN+/-nn,nn+/-n,nnnnnnn DPB

N/T/S/I+/-nn,nn+/-n,nnnnnnn DPB

N/T/S/Inn

APROAPE+/-nn,nn+/-n,nnnnnnn DPB

N/T/S/I+/-nn,nn+/-n,nnnnnnn DPB

N/T/S/Inn

(X)Lentile de contact: Tip: text 50 caractere

Raza: n,n mmDiametru: nn,n

OD: sfera: +/- nn,nn cilindru: +/- nn,nn ax: nnnOS: sfera: +/- nn,nn cilindru: +/- nn,nn ax: nnn(X)Proba lentile de contact.RECOMANDRI : textFiecare pagina va fi numerotata si va avea sus antet si datele de identificare pacient, iar jos data si dr.DATA.. Dr.