Eye Examination Record
Patient Information
Name: Sarah Jenkins
NHS Number: 123 456 7890
Address: 12 Orchard Lane, Bristol, BS1 5YZ
Tel: 07700 900333
Email: sarah.jenkins@example.com
GP: Dr. Eleanor Vance
Present at Examination: Patient only
Alternative Contact: Mr. David Jenkins, Husband, 07700 900444
NHS Sight Test Eligibility
Reason for Test: Patient has a family history of glaucoma and is over 60 years old.
Domiciliary Eligibility Reason
Reason: Patient is unable to leave home unaccompanied due to severe mobility impairment following a stroke.
History & Symptoms
Patient reports gradually worsening blurred vision in both eyes over the past 6 months, particularly when reading. Experiences occasional headaches, mainly in the evenings. Denies flashes, floaters, or pain. Reports difficulty with night driving.
General Health
Controlled hypertension (diagnosed 5 years ago). History of mild osteoarthritis. Non-smoker, rarely drinks alcohol. No known allergies.
Medications
Lisinopril 10mg OD for hypertension.
Ocular History
Last eye examination 2 years ago, reported good vision. No history of ocular surgery, trauma, or infections. Wears reading glasses purchased over-the-counter.
Family History
Mother diagnosed with glaucoma at age 70. Father had cataracts removed in his 80s. Maternal grandfather had macular degeneration.
Hobbies/Tasks
Enjoys reading, knitting, and watching television. Previously enjoyed gardening but finds it difficult now due to vision and mobility issues. Requires clear vision for daily tasks around the home.
Current Prescription & Visual Acuity
Current Spectacles (Reading, ~2 yrs old):
R: +2.00 DS
L: +2.00 DS
Distance VA with current specs: R: 6/12, L: 6/18
Near VA with current specs: N8 at 35cm, struggling with small print.
Pupils
PERRLA, direct and consensual reflexes brisk. No anisocoria.
RAPD: Negative.
Retinoscopy
R: +0.75 / -0.25 x 180
L: +1.00 / -0.50 x 5
PD: 62mm
Subjective Refraction
R: +0.75 / -0.25 x 180 (6/6)
L: +1.00 / -0.50 x 5 (6/7.5)
Add: +2.50 DS (N5 at 35cm)
Tonometry
Method: Icare tonometer
R: 16 mmHg
L: 17 mmHg
Time: 14:30
Drops Used: Proxymetacaine 0.5% (prior to tonometry), Tropicamide 1% (for dilation)
Batch No: PX12345, TR67890
Expiry: 11/2025, 03/2026
OMB/Motility
Full range of extraocular movements. Orthophoric at distance and near. No nystagmus. Cover test negative for phoria/tropia. Stereopsis reduced (600 arc seconds).
External Examination
Lids/Lashes: Mild blepharitis noted bilaterally, few misdirected lashes. No ptosis or lagophthalmos.
Conj/Sclera: Clear and white, no injection or pterygium.
Anterior Segment
Cornea: Clear, no opacities or staining.
AC: Deep and clear, no cells or flare.
Lens: Nuclear sclerosis grade 2+ bilaterally, no cortical or posterior subcapsular changes.
Ophthalmoscopy
Media: Clear, mild nuclear sclerosis noted.
Fundus: Healthy appearance bilaterally.
Vessels: Normal calibre and tortuosity, no haemorrhages or exudates.
Macula: Clear, no drusen or signs of macular oedema.
Disc: Pink and healthy, C/D ratio R: 0.4, L: 0.4, symmetrical, good neuro-retinal rim. No peripapillary atrophy.
Dilation: Yes
Visual Fields
R: Full to confrontation
L: Full to confrontation
Final Prescription
R: +0.75 / -0.25 x 180 Add +2.50 (DVA: 6/6, NVA: N5)
L: +1.00 / -0.50 x 5 Add +2.50 (DVA: 6/7.5, NVA: N5)
Comment
Patient has early cataracts affecting visual acuity, particularly at near. Refraction shows a slight hyperopic shift. Mild blepharitis managed with lid hygiene. Intraocular pressures are within normal limits. Family history of glaucoma noted, will monitor closely.
Action
1. Advised patient new distance and reading spectacles based on subjective refraction.
2. Recommended warm compresses and lid hygiene for blepharitis.
3. Discussed early cataract development and advised regular monitoring.
4. Provided information on glaucoma due to family history and importance of regular check-ups.
5. Eligible for NHS GOS3 voucher.
Recall
Advised for routine eye examination in 12 months, or sooner if symptoms worsen.
Type of Examination
NHS GOS1
Declaration
I declare that I have personally carried out the sight test detailed above on 1 November 2024 and that in my professional opinion the test was necessary. I also declare that to the best of my knowledge and belief the patient meets the eligibility criteria for an NHS sight test.
Optometrist
Name: Dr. Thomas Kelly
GOC Number: 012345
**Eye Examination Record**
**Patient Information**
Name: [patient full name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
NHS Number: [patient NHS number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Address: [patient address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Tel: [patient telephone number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Email: [patient email address] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
GP: [general practitioner name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Present at Examination: [individuals present at the examination] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Alternative Contact: [alternative contact name], [relationship to patient], [alternative contact telephone number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**NHS Sight Test Eligibility**
(Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Reason for Test: [reason for NHS sight test eligibility, e.g., patient has diabetes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Domiciliary Eligibility Reason**
(Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Reason: [reason for domiciliary eligibility, e.g., unable to leave home unaccompanied due to disability] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**History & Symptoms**
[presenting symptoms and chief complaints] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**General Health**
[general health status and systemic conditions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Medications**
[current medications and dosages] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Ocular History**
[previous eye conditions, surgeries, and treatments] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Family History**
[relevant family ocular and medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Hobbies/Tasks**
[relevant activities and visual demands] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Current Prescription & Visual Acuity**
(Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Current Spectacles ([type and age of current spectacles e.g. Distance, ~3 yrs old]):
R: [right eye current spectacle prescription] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
L: [left eye current spectacle prescription] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Distance VA with current specs: R: [right eye distance visual acuity with current spectacles], L: [left eye distance visual acuity with current spectacles] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Near VA with current specs: [near visual acuity with current spectacles, including reading distance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Pupils**
[pupil examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
RAPD: [relative afferent pupillary defect findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Retinoscopy**
R: [right eye retinoscopy findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
L: [left eye retinoscopy findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
PD: [pupillary distance measurement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Subjective Refraction**
R: [right eye subjective refraction values including sphere, cylinder, axis, and final visual acuity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
L: [left eye subjective refraction values including sphere, cylinder, axis, and final visual acuity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Add: [reading addition value and near visual acuity achieved] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Tonometry**
Method: [tonometry method used] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
R: [right eye intraocular pressure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
L: [left eye intraocular pressure] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Time: [time of measurement] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Drops Used: [name and percentage of drops used for dilation or tonometry] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Batch No: [batch number of drops used] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Expiry: [expiry date of drops used in MM/YYYY format] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**OMB/Motility**
[ocular motility and binocular vision findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**External Examination**
Lids/Lashes: [eyelid and eyelash examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Conj/Sclera: [conjunctiva and sclera examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Anterior Segment**
Cornea: [corneal examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
AC: [anterior chamber examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Lens: [lens examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Ophthalmoscopy**
Media: [ocular media clarity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Fundus: [general fundus appearance] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Vessels: [retinal vessel examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Macula: [macular examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Disc: [optic disc examination findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
Dilation: [dilation status e.g. Yes or No] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Visual Fields**
R: [right eye visual field results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
L: [left eye visual field results] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Final Prescription**
R: [right eye final prescription including sphere, cylinder, axis, addition, near visual acuity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
L: [left eye final prescription including sphere, cylinder, axis, addition, near visual acuity] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Comment**
[additional comments and observations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Action**
[recommended actions and treatment plan, including GOS3 voucher eligibility status] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely. List as a numbered list.)
**Recall**
[follow-up appointment recommendations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Type of Examination**
[type of examination, e.g., Private, NHS GOS1, EHEW Band x] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
**Declaration**
(Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
[NHS-compliant declaration statement regarding the sight test] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
**Optometrist**
(Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit section entirely)
Name: [optometrist name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
GOC Number: [optometrist GOC number] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely)
