OptiAI Rx

Auto Refractometer & Pupil Screening Req

Auto Refraction

Sph — OD*

Sph — OS*

Cyl — OD*

Cyl — OS*

Axis — OD*

Axis — OS*

Autorefraction Measurement Quality*

Pupil Observation

Apparent pupil size is a qualitative observation only.

Apparent Pupil Size — OD (Room Light)*

Apparent Pupil Size — OS (Room Light)*

Pupil Symmetry — Room Light*

Pupillary Light Response

Direct Response — OD*

Direct Response — OS*

Consensual Response — OD*

Consensual Response — OS*

RAPD Status*

Assess using swinging flashlight test.

Dim-Light Observation

Dim-Light Pupil Dilation*

Qualitative observation; not formal mesopic pupillometry.

Case History Req

Name*

Age*

Phone Number*

Occupation

Medical Professional / Chef (mask or heat-exposure occupation)?

Task priority*

Computer hours*

Reading hours*

Focused work hours*

Office user hours

Profession / Primary Work Type

Does the patient need to see people or screens across a room — meetings, teaching, presentations?*

Chief complaint*

Chief complaint severity*

Driving

First-time wearer?*

Previous lens*

Adaptation*

Expectation*

Ocular history (select all that apply)*

Systemic health*

Symptom onset

Last eye exam*

Ocular-risk medication*

Search History

Lens Profiler

Phone Number

Frame Check

Phone Number

Behaviour Score Req

Total0/27

Working Distances (cm)

Phone

Laptop

Dashboard

Counter

Primary monitor

Reading

Active Complaints All categories required

Existing RX Req

Frame

Lens

Stability

Old Rx *

Sph

Cyl

Ax

Add

Right OD

Left OS

Old Rx dispensed by *

Lens HutOutside RxNA

Complaint reproduced with current glasses?

Visual Acuity Req

Test	Right OD	Left OS	Status
Distance VA Unaided*
Near VA Unaided*
Distance VA With Current Glasses*
Near VA with Current Lenses*
Intermediate VA with Current Lenses
Distance VA Pinhole*

Pinhole Right OD*

Pinhole Left OS*

Confrontation fields*

Colour & Torch Req

Ishihara — plates correct*

Ishihara — plates shown*

Colour defect onset*

Ishihara — staff interpretation*

Amsler*

Tear film

Blink

Light Sensitivity questionnaire (10–100) —

10 low10100 high

Photophobia specifically reported / identified?

Light sensitive concern during travel?

Binocular Vision BV

EOM (eye movements)*

Cover test dist*

Cover test near*

NPC (RAF Ruler)

Worth 4 Dot*

Stereopsis

Fus reserves

Maddox dist

Maddox near

Maddox vertical

Prism req

Refraction Req

Subjective Rx* (all fields required)

Sph

Cyl

Ax

Dist VA

Add

Near VA

Right OD

Left OS

New Rx dispensed by *

Lens HutOutside Rx

Duochrome*

Bino balance*

JCC*

Post-refraction tests (with final Rx in place)

Glare

Contrast (Pelli-Robson)*

Dominant eye*

Accommodation Adv

NPA / Amplitude (RAF Ruler)

NRA

PRA

Flipper

Near-far rock

Pre-presbyopic symptoms

Notes

Final Validation Req

Distance

Near

Intermediate

Comments

Staff sign-off*

Examining optometrist*

Generate releases the recommendation under the named optometrist.