RX CHECK / NEW GLASSES COMPLAINT EVALUATION

FOR OPTICAL REVIEW PRIOR TO OD CHECK

Patient Name: DOB: Date:
Optician: Provider: Days Since Dispense:
Type:

I. Chief Complaint

Patient's own words:
Vision Symptoms:





Comfort / Function:





Timing & Onset:



Better in old glasses?


II. Previous Eyewear Comparison Previous available?

Parameter Old Eyewear New Eyewear Notable Changes (Check all that apply)
Rx Date



Lens/Material
Frame Style
PD / Seg

III. Order & Lensometry Verification

Matches invoice/Rx?
Lens Defects?
EYE ORDERED (Sph - Cyl x Axis | Add | Prism) VERIFIED
OD
OS
Lens Worn:
Material/Treatments:
Verification:

IV. Measurements & Dispensing Fit

Measured PD: OD OS

Measured Seg: OD OS
Alignment:


Fit Check:

V. Troubleshooting & Optician Assessment

Performed:
Did troubleshooting improve symptoms?
Assessment: Appears most consistent with:
Optician Notes:
Optician Signature:
Date/Time:

VI. Red Flag Symptoms (Notify Provider Promptly)

       

VII. Provider Follow-Up (Clinical Use Only)

Findings / Plan:
         
Provider Notes:
Provider Signature:
Date/Time:
Complete optical verification prior to provider re-evaluation when appropriate.