Optometry Case Record and Refraction Template: Printable Case History, Refraction and Prescription Sheet
Last updated: November 2026
RPC Rounds for Optometrists · B.Optom study guide
A one-page case record for refraction clinics, college practicals and optical practices. Print it (only the sheet prints), use it for every patient, and keep it with the patient's file. Good records protect the patient and you.
Prints on one A4 page; set margins to "narrow" if needed.
Optometry Case Record
| Name | Date | ||
| Age / sex | Record no. | ||
| Occupation | Phone |
History
| Chief complaint (what, which eye, since when) | |
| Ocular history (glasses, contact lenses, surgery, injury, amblyopia, squint) | |
| Systemic history (diabetes, BP, thyroid, other) | |
| Medicines and allergies | |
| Family history (glaucoma, high myopia, squint, retinal disease) | |
| Visual needs (screen, driving, reading distance, hobbies) |
Vision and refraction
| Unaided D | Unaided N | Pinhole | Old glasses (power) | VA with old | |
|---|---|---|---|---|---|
| R | |||||
| L |
| Retinoscopy (WD ___ cm) | Sph | Cyl | Axis | VA | Add | Near VA | |
|---|---|---|---|---|---|---|---|
| R | |||||||
| L |
Cycloplegic: yes / no Drug and time: ________ Binocular balance: ________ Duochrome: ________
Binocular vision
| Cover test D / N | NPC (cm) | ||
| Motility | Stereo / Worth | ||
| Amplitude of accommodation R / L | Colour vision |
Eye health
| R | L | |
|---|---|---|
| Lids and lashes | ||
| Conjunctiva and cornea | ||
| Anterior chamber (van Herick) | ||
| Pupils (RAPD) | ||
| Lens | ||
| IOP (method, time) | ||
| Disc (C:D) and macula |
Final prescription
| Sph | Cyl | Axis | Prism / base | Add | VA | |
|---|---|---|---|---|---|---|
| R | ||||||
| L |
PD: distance ______ near ______ Lens advised: single vision / bifocal / progressive / office Material and coatings: __________
Advice given: ____________________________________________
Referral: none / routine / within 1 week / same day To: __________ Reason: __________
Review date: __________ Examined by (name and signature): __________________
How to fill it in well
- History first: a good history tells you what to look for. Ask open questions, then specific ones about flashes, floaters, headaches, double vision and pain.
- Write the method: chart and distance for acuity, working distance for retinoscopy, cycloplegic drug and time, and tonometer and time for IOP.
- Record negatives that matter: "no RAPD", "van Herick grade 4", "no flashes".
- Prescription: axis in three digits, sign on every number, add and prism with base direction, PD.
- Referral: tick the urgency and write the reason; use the referral guide.
- Keep records for as long as your state rules and clinic policy require; children's records usually longer.
Common abbreviations
| Abbreviation | Meaning |
|---|---|
| VA, D, N | Visual acuity, distance, near |
| PH | Pinhole |
| WD | Working distance |
| DS / DC | Dioptre sphere / dioptre cylinder |
| MPMVA | Maximum plus for best visual acuity |
| NPC | Near point of convergence |
| RAPD | Relative afferent pupillary defect |
| C:D | Cup-to-disc ratio |
| PD | Pupillary distance |
| BO / BI / BU / BD | Base out, in, up, down |
Practical pearls
- Fill in the history before you touch an instrument; it guides the whole examination.
- Write the working distance next to retinoscopy every time.
- Note the time of IOP measurement; IOP varies through the day.
Where students slip
- Leaving the axis as two digits ("45" instead of "045").
- Not recording which eye was tested first or whether glasses were worn.
- No referral reason written on the record.
Test yourself: flip cards
Quick quiz
Related: Subjective Refraction Step by Step: Fogging, Best Sphere, Cross-Cylinder, Binocular Balance and Near Add, When to Refer: Eye Referral Urgency Guide for Optometrists, B.Optom Practical and Viva Stations: 30 OSCE-Style Stations With Model Answers, How to Read Your Glasses Prescription: SPH, CYL, AXIS, ADD, Day 1 in the Eye OPD: Pocket Checklist for Junior Residents. Back to the optometry curriculum.
Key sources
- College of Optometrists. Guidance for Professional Practice: patient records. college-optometrists.org
- Elliott DB. Clinical Procedures in Primary Eye Care. 5th ed. Elsevier; 2020
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