IDENTIFICAÇÃO

EXAME
Data: / / Idade: _____ _____
OFTALMOLÓGICO Nome:
Professor: Profissão:
Aluno:
Obs:

ANAMNESE
Queixa principal: _
Outras queixas: __
OLHOS

História oftalmológica: _
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Antecedentes patológicos: ______________________________________________________

GERAL

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Medicações: _ _ _
Antecedentes familiares: _ _

EXAME OFTALMOLÓGICO
ACUIDADE VISUAL CORREÇÃO ÓPTICA AUTORREFRAÇÃO
SEM CORREÇÃO COM CORREÇÃO
OD: ^ a OD: ^ a
OD: _ / _ J: OD: _ / _ J:
OE: ^ a OE: ^ a
OE: _ / _ OE: _ / _
AD:

REFLEXOS
TONOMETRIA TESTE DE LENTES
OD: mmHg OD: ^ a ____/____ Bell
Vermelho
OE: mmHg OE: ^ a ____/____
Pupilar Aferente
AD:
CERATOMETRIA Pupilar Eferente

OD: ^ a
OE: ^ a ALTERAÇÕES NA
ECTOSCOPIA

MOTILIDADE
OCULAR

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PPC:____________________________
Hirschberg:_____________________
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 BIOMICROSCOPIA

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OD

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OE

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FUNDOSCOPIA
OD OE

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CONDUTA HIPÓTESES DIAGNÓSTICAS

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PLANO
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