Eye Examination

POHC No:

VISION

Distant vision (without glasses)	Near vision (without glasses)	Distant vision (with glasses)	Near vision (with glasses)	color vision as per ishihara's chart
LEFT EYE RIGHT EYE	LEFT EYE RIGHT EYE	LEFT EYE RIGHT EYE	LEFT EYE RIGHT EYE	BOTH EYES
6/ 6/	N/ N/	6/ 6/	N/ N/	> Normal />Defective

Refractive Power	Right eye				left eye
Refractive Power	dsph	dcyl	axis	v	dsph	dcyl	axis	v
distance
Near(reading)

C/o:
O.exam:
Prev. Diagnosis:
Treatment and Advice:

Opinion/ Remarks (By Opthalmologist)
<?php echo $opinion_remarks_medical_assistant?>

next checkup date	">
approval date

Opinion of the MO	type="radio" name="physical_status" id="physical_status" value="FIT" /> FIT type="radio" name="physical_status" id="physical_status" value="UNFIT" /> UNFIT FIT UNFIT
Opinion/ Remarks (By Doctor)	<?php echo $opinion_remarks?>