SIMPLES COMPLETO PAGTO_________________________________________

CLIENTE_______________________________________________________ CPF _______________________

ENDEREÇO __________________________________________________________ DATA _____/_____/_____
TELEFONE _________________________ DATA NASC.: _____/_____/_____ IDADE: _________ ANOS

ÚLTIMA AVALIAÇÃO: ________ANOS _______ MESES ONDE___________________ 1ª VEZ

AUTO-REFRATOR CERATOMETRIA DIF. CORNEANA
OD ______ ______ x ______ ________x________ x _____/_____ ________ x _________
OE ______ ______ x ______ ________x________ x _____/_____ ________ x __________
RETINOSCOPIA OD______________________________________ OE_______________________________________

DIOPTRIA FINAL AD AV C/C AV S/C DIOPTRIA ANTERIOR _________ ADIÇÃO

OD _____ _____ x _____ _____ ____/____ ____/____ OD ______ ______ x ____ ______
OE _____ _____ x _____ _____ ____/____ ____/____ OE ______ ______ x ____ ______

LENTE MULT. BIFOC. AR. TRANSI. ________________________________

ANAMNESE ___ DIABETES ____________________________________
___HIPERTENSÃO _______________________________ GLICEMIA ____________mg/dL data ____/_____/____
___GLAUCOMA ________________________________ ANTECEDENTE FAMILIAR ___________________________
___TIROIDES ___________________________________ CIRURGIAS ______________________________________
OBSERVAÇÕES E MEDICAMENTOS_____________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
OFTALMOSCOPIA_________________________________________________________________________________
COVER_____________________________________ TORRINGTON_______________________________________
PPC: SC_____________CC _____________________ LUZ DE WORTH_______________________________________
Obs.:________________________________________ AMSLER
____________________________________________
____________________________________________ OD OE
____________________________________________
ESCAVAÇÃO OD_______ OE_______
1 2 2 1
OD OE
A B N.O. N.O. B A

C D DC
3 4 4 3

DISCO ÓPTICO__________________________ CRISTALINO ____________________________

______________________________________ ______________________________________
VÉIAS e ARTÉRIAS_______________________ HIPOTRANSPARÊNCIA OD OE ENDURECIMENTO OD OE
______________________________________ PITERÍGIO______________________________
RETINA________________________________ ______________________________________
______________________________________ OBS.:__________________________________
MÁCULA_______________________________ ______________________________________