Aviation Medical Services Eye Examination Form - Qantas

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REFRACTION: R L Sph. Cyl. Axis Add VISUAL ACUITY: R L - uncorrected 6/ 6/ - corrected 6/ 6/ Near Point (cm) COLOUR VISION: Ishihara Plates; score number of errors AUTOMATED PERIMETRY: Normal Abnormal Comment on any abnormality _________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ COVER TEST: Distance Near MADDOX ROD: Horizontal Vertical OCULAR MOTILITY: Normal Abnormal Comment on any abnormality _________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Pilot Eye Examination V7.1 December 2008 2
COVERGENCE (CM): PUPILS: Are pupils equal? Yes No Is there RAPD (relative afferent pupil defect)? Yes No INTRA-OCULAR PRESSURE (mm Hg): R L Instrument: Goldmann Perkins Tonopen Non-Contact Tonometer Other_________ DILATED PUPIL EXAMINATION: Is there any corneal disease? Yes No Are there any lens opacities? Yes No Is there any macular disease? Yes No Is there any peripheral retinal pathology? Yes No Are the optic discs healthy? Yes No Comment on any abnormality _________________________________________________ __________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________ Is there any other ocular pathology? __________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ Name and address of CASA Designated Aviation Ophthalmologist (Block letters or stamp): ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ DAO’s Signature: __________________________________________ Date: __________________ DAO CASA Number:_______________________________________ Pilot Eye Examination V7.1 December 2008 3
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Aviation Medical Services Eye Examination Form - Qantas

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