Optometry Contact Lens Fitting Assessment

Optometry Contact Lens Fitting Assessment — Form Fields

This healthcare template includes 15 fields. Assessment form for optometrists evaluating patients for contact lens fitting. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Date of Birth (text, required)
• Optometrist Name (text, required)
• Assessment Date (text, required)
• Lens Type (dropdown selection, required) — options: Daily Disposable, Bi-Weekly, Monthly, Rigid Gas Permeable, Scleral, Toric (Astigmatism), Multifocal, Cosmetic/Color
• Right Eye Prescription (SPH CYL AXIS) (text, required)
• Left Eye Prescription (SPH CYL AXIS) (text, required)
• Base Curve (text, required)
• Diameter (text, required)
• Tear Film Quality (dropdown selection, required) — options: Adequate, Borderline Dry, Dry, Very Dry
• Previous Contact Lens Wearer (multiple choice, required) — options: Yes, No
• Wearing Schedule (dropdown selection, required) — options: Full Time, Part Time, Occasional, Sports Only
• Eye Conditions (checkboxes, optional) — options: Dry Eye, Allergies, Keratoconus, Astigmatism, Presbyopia, Giant Papillary Conjunctivitis, None
• Trial Lens Dispensed (multiple choice, required) — options: Yes, No
• Fitting Notes and Follow-Up Plan (long text, optional)