STEREO OPTICAL PRESCREENING RECORD FORM FOR THE OPTEC® VISION TESTER

NAME: DATE: 

ADDRESS: AGE: 

CITY, STATE, ZIP: WEARING GLASSES: Y   N

ADMINISTRATOR: CONTACT LENSES: Y   N

PERIPHERAL TEST   L =   85°    70°    55°    45° R =   

85°    
70°  55°    45°
  

DIAL AT 01:  ACUITY – FAR DIAL AT 03:  ACUITY – NEAR

Score: 20/   Score: 20/   Score: 20/   Score: 20/   Score: 20/   Score: 20/  
LINE/ACUITY LEFT EYE BOTH EYES RIGHT EYE LINE/ACUITY LEFT EYE BOTH EYES RIGHT EYE
1 20/200 ZN RO HK 1 20/100 SVC NRK HZO
2 20/100 RKS HNC ZOD 2 20/70 RNZH DOKV CSZN
3 20/70 HCDV SKZO RNDS 3 20/50 CKVD SNZR DOHC
4 20/50 ZROD NSCH VZKN 4 20/40 VHRN ODSK NZCS
5 20/40 KHSC OZNR DNVC 5 20/30 HSKRC NZDOV ZSHNK
6 20/30 ONRZV DKHCS KDSON 6 20/20 ZONVR HCSKD VKCDS
7 20/20 SDCHN VRZKO HSNRD

DIAL AT 02: COLOR PERCEPTION – FAR A -1 2  B-5 C-2 6 D-6 E-1 6 F-BLANK PASS  FAIL
DIAL AT 04: LATERAL PHORIA – FAR Score: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
PRISM DIOPTERS ESOPHORIA ORTHO EXOPHORIA

DIAL AT 05: VERTICAL PHORIA – FAR Score: 1 2 3 4 5 6 7

1/2 PRISM DIOPTERS LEFT HYPERPHORIA ORTHO RIGHT HYPERPHORIA
DIAL AT 06: LATERAL PHORIA – NEAR Score: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
1 PRISM DIOPTERS ESOPHORIA ORTHO EXOPHORIA
DIAL AT 07: DEPTH PERCEPTION – FAR 1-B 2-L 3-B 4-T 5-T 6-L 7-R 8-L 9-R Score:
SECONDS OF ARC 400 200 100 70 50 40 30 25 20

DIAL AT 08: FUSION – FAR 3 cubes BOTH eyes = PASS Other than 3 cubes = FAIL   PASS  FAIL
DIAL AT 09: LEFT EYE  Score: 20/ Right Occluder OFF RIGHT EYE  Score: 20/ Left Occluder OFF
 TUMBLING 20 20 20 20 20 20 20 20 20 20 20 20 20 20
“E” FAR PILOT PILOT
200 100 70 50 40 30 20 200 100 70 50 40 30 20
LINE 1 2 3 4 5 6 LINE 1 2 3 4 5 6
LINE/ACUITY COLOR L T B L R L T LINE/ACUITY R B R L L T B
A 20/50 BLUE R T R L T B A 20/50 L R T L B T
B 20/40 RED B R B L L R B 20/40 T T L B T R
C 20/30 AMBER L T T L R B C 20/30 L B R R L T
D 20/20 GREEN R L T L B T D 20/20 R T R L T B

DIAL AT 10: COLOR PERCEPTION – FAR 1-R 2-L 3-B 4-T 5-B 6-L 7-T 8-R

DIAL AT 11: MUSCLE BALANCE - FAR Ball IN Box = PASS Ball OUT of Box = FAIL
DIAL AT 12: LINE ACUITY COLOR BOTH EYES
20/100 CAR, PHONE, CAKE, HORSE Y  N
LEFT EYE  Score 20/ RIGHT EYE  Score 20/
ALLEN PRE- A 20/50 BLUE Y  N HORSE, CAKE, PHONE CAR CAKE, HORSE, CAR, PHONE
SCHOOL B 20/40 RED Y  N CAKE, CAR, HORSE, PHONE PHONE, CAKE, HORSE, CAR
FAR C 20/30 YELLOW Y  N PHONE, HORSE, CAR, CAKE HORSE, CAR, PHONE, CAKE

STEREO OPTICAL CO., INC. Clear Form Save Form

8600 W. Catalpa Avenue, Suite 703
Chicago, IL 60656
773.867.0380
www.stereooptical.com | info@stereooptical.com
© Stereo Optical Co., Inc. 10/2020. All rights reserved. Unless indicated otherwise, all
trademarks are the property of Stereo Optical Co., Inc. in the United States and other countries. P/N 56218