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Home
About Us
Mission & Vision
Board of Management
Our Supporters
Staff Mail
Contact Us
OPTHALMIC NURSES SYMPOSIUM
Screening
FAQs
Services
Eye Care Services
General Out Patient & Executive Clinic
Vitreo-Retinal Clinic
Glaucoma Clinic
LASIK
Optical Centre
Low Vision Clinic
Pediatric Ophthalmology
Orbital Oculoplasty
Eye Glossary
Dental Unit
Hearing Unit
Eye Bank
Community Eye Care
Laboratory Services
Training
Diabetes Care Center
Book Appointment
Donate
Make A Donation
Partner With Us
Corporate Tie-Ups
Corporate Eye Check-Ups
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News & Events
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Screening Form
GENERAL INFORMATION
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Additional Information
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Patient Has NHIF / Insurance Coverage?
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ID Number
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BRIEF MEDICAL HISTORY
Known Diabetic
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High Blood Pressure
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Cardiovascular Disease
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Any Breathing Difficulties
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Any Known Allergies To Medication? {COPD/Asthma}
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Others
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Specify
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EYE SCREENING FORM
VA WITH GLASSES
Left Eye
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5
CF5m
CF4m
CF3m
CF2m
CF1m
Hm
PL
NV
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Right Eye
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5
CF5m
CF4m
CF3m
CF2m
CF1m
Hm
PL
NV
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VA WITHOUT GLASSES
Left Eye
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5
CF5m
CF4m
CF3m
CF2m
CF1m
Hm
PL
NV
Invalid Input
Right Eye
6/60
6/36
6/24
6/18
6/12
6/9
6/6
6/5
CF5m
CF4m
CF3m
CF2m
CF1m
Hm
PL
NV
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Refraction
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No
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Value For Refraction
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Doctors Eye Consultation
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Doctor Comments
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Cataract Surgery Required
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Glaucoma
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Keratoconus
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Squint
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Other eye surgery required?
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BMI READINGS
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DOCTOR COMMENTS
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Referral
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