ICEID EYE CENTRE
Contact Lens Assessment, Fitting & Follow-up Record
1. Patient Biodata
Patient Name
Patient ID
Date of Birth
Age
Sex
Male
Female
Date of Examination
Referred By
Occupation / School
2. Contact Lens History & Patient Questionnaire
Reason for Contact Lens Wear
Cosmetic / appearance
Sports / physical activity
Occupational needs
Social occasions
Replacement of current lenses
Spectacle intolerance
High refractive error
Myopia control
Presbyopic correction
Therapeutic / medical indication
Other reason
What does the patient expect to achieve with contact lenses?
Previous Contact Lens Wear
Previously worn contact lenses?
No
Yes
Previous Brand / Type
Previous Lens Modality
Daily disposable
Two-weekly
Monthly
Conventional / yearly
Rigid Gas Permeable
Previous Material
Silicone hydrogel
Hydrogel
Rigid Gas Permeable
Hybrid
Other
Days worn per week
Hours worn per day
Previous care solution
Reason for discontinuation / desire to change
Dryness / discomfort
Blurred vision / poor vision
Glare / halos
Cost
Convenience
Handling difficulty
Presbyopic symptoms
Recurrent redness
Other
Previous Compliance
Slept in lenses?
Never
Sometimes
Often
Replaced lens case regularly?
Yes
No
Sometimes
Ever topped-up old solution?
No
Yes
Sometimes
Ever exposed lenses to tap water?
No
Yes
Sometimes
Swims / showers in lenses?
No
Yes
Sometimes
Ocular & Medical History
Previous ocular surgery
Previous ocular trauma
Amblyopia
Strabismus
Glaucoma
Cataract
Recurrent corneal erosion
Corneal disease
Diabetes
Hypertension
Thyroid disorder
Autoimmune disease
Allergy / atopy
Relevant medical / ocular history
Current medications including eye drops
Known allergies
Dry Eye / Ocular Surface Symptoms
Dryness
Grittiness
Burning
Redness
Watering
Itching
Photophobia
Fluctuating vision
Lubricating drops currently used
Lifestyle & Occupational Assessment
Average screen time per day
Typical working environment
Air-conditioned environment
Dusty / dry environment
Chemical exposure
Outdoor / UV exposure
Sports
Water sports
Frequent travel
Demanding visual tasks
Special Visual Needs
Astigmatism correction
Presbyopia / near correction
Myopia control
Irregular cornea
High ametropia
Anisometropia
Cosmetic / prosthetic need
3. Pre-Fitting Examination
Visual Acuity
Right Eye (OD)
Left Eye (OS)
Both Eyes (OU)
Unaided Distance Visual Acuity
Aided Distance Visual Acuity
Near Visual Acuity
External / Slit-Lamp Examination
Lids
Lashes
Lid margins
Blink quality
Conjunctiva
Cornea
Anterior chamber
Iris
Lens
Other pre-fitting findings
4. Refraction
Sphere
Cylinder
Axis
Add
Best Corrected Visual Acuity
Right Eye (OD)
Left Eye (OS)
Binocular balance / refraction comments
5. Keratometry & Corneal Assessment
Eye
Flat K (K1)
Axis
Steep K (K2)
Axis
Corneal Astigmatism
Right Eye (OD)
Left Eye (OS)
Horizontal Visible Iris Diameter (HVID) - OD
Horizontal Visible Iris Diameter (HVID) - OS
Photopic Pupil Size
Mesopic Pupil Size
Corneal Topography Performed?
No
Yes
Corneal Eccentricity / Shape
Topography / corneal morphology comments
6. Tear Film & Ocular-Surface Assessment
Test
Right Eye (OD)
Left Eye (OS)
Non-Invasive Tear Break-Up Time (NIBUT)
Tear Break-Up Time (TBUT)
Tear Meniscus Height
Schirmer Test
Corneal Staining
Conjunctival Staining
Meibomian Gland / Lid Margin Assessment
InflammaDry / Matrix Metalloproteinase-9 (MMP-9)
Not done
Negative
Positive
Dry Eye Analyzer Findings
Contact Lens Suitability of Ocular Surface
Suitable
Suitable with management / modification
Temporarily unsuitable
Contraindicated
Ocular-surface comments / treatment required before fitting
7. Contact Lens Type Selection
Recommended Lens Category
Soft Spherical
Soft Toric
Soft Multifocal
Soft Toric Multifocal
Rigid Gas Permeable (RGP)
Multifocal RGP
Hybrid
Myopia Control Soft Lens
Orthokeratology
Scleral / Specialty Lens
Cosmetic / Prosthetic Lens
Other
Intended Modality
Daily disposable
Two-weekly
Monthly
Conventional
Wearing Schedule
Daily wear
Part-time wear
Extended wear only if specifically prescribed
Material Preference
Silicone hydrogel
Hydrogel
Rigid Gas Permeable
Hybrid
Other
Clinical rationale for lens choice
8. Trial / Diagnostic Lens
Right Eye (OD)
Left Eye (OS)
Brand / Design
Material
Base Curve (BC)
Diameter (DIA)
Sphere Power
Cylinder
Axis
Add Power
Settling time before fit assessment
9. Contact Lens Fit Assessment
Soft Lens Assessment
Parameter
Right Eye (OD)
Left Eye (OS)
Centration
Corneal Coverage
Movement on Blink
Push-Up Test
Comfort
Toric Lens Assessment
Parameter
Right Eye (OD)
Left Eye (OS)
Orientation / Rotation
Direction of Rotation
Rotational Stability
Multifocal Lens Assessment
Parameter
Right Eye (OD)
Left Eye (OS)
Distance Vision
Intermediate Vision
Near Vision
Rigid Gas Permeable (RGP) / Specialty Lens Assessment
Parameter
Right Eye (OD)
Left Eye (OS)
Centration
Movement
Fluorescein Pattern
Edge Lift
Apical / Bearing Relationship
Comfort
Overall fit assessment
Optimal / acceptable
Too tight / steep
Too loose / flat
Excessive movement
Poor centration
Unstable rotation
Needs alternative design
Fit modification required
10. Over-Refraction & Visual Acuity
Right Eye (OD)
Left Eye (OS)
Spherical Over-Refraction
Cylindrical Over-Refraction
Axis
Distance Visual Acuity with Lens
Near Visual Acuity with Lens
Binocular Distance Visual Acuity (OU)
Binocular Near Visual Acuity (OU)
Over-refraction / visual performance comments
11. Final Contact Lens Prescription
Lens Brand / Design
Replacement Modality
Care System
Recommended Wearing Schedule
Eye
Base Curve
Diameter
Sphere
Cylinder
Axis
Add
Right Eye (OD)
Left Eye (OS)
Additional prescription notes
12. Patient Education & Contact Lens Care
Hand washing demonstrated
Insertion training completed
Removal training completed
Cleaning / disinfection demonstrated
Replacement schedule explained
Lens case care explained
No topping-up old solution explained
Avoid tap-water exposure explained
Avoid swimming / showering in lenses explained
No sleeping in lenses unless specifically prescribed
Cosmetics / lens handling advice given
Maximum daily wearing time explained
Contact Lens Red Flags:
Patient advised to discontinue lens wear and seek prompt eye-care review for pain, significant redness, photophobia, discharge, sudden blurred vision or persistent discomfort.
Red-flag symptoms explained
Patient demonstrated safe handling
Written / verbal care instructions provided
Patient education comments
13. Clinical Assessment / Diagnosis
Suitable for contact lens wear
Soft spherical lens candidate
Soft toric lens candidate
Multifocal contact lens candidate
Rigid Gas Permeable lens candidate
Specialty lens candidate
Myopia-control lens candidate
Ocular-surface disease requiring treatment
Contact-lens intolerance
Contact-lens associated dry eye
Contact-lens associated keratitis / inflammation suspected
Contact lens wear temporarily contraindicated
Primary Clinical Assessment / Diagnosis
Secondary Assessment / Diagnosis
Clinical Comments
14. Management & Follow-Up
Contact lenses prescribed
Trial lens ordered / dispensed
Alternative lens design required
Ocular-surface treatment commenced
Dry-eye management required
Contact lens wear suspended temporarily
Referral required
Routine review
Management Plan
Recommended days/week
Maximum hours/day
Follow-up interval
Follow-up date
Parameters to review at follow-up
15. Clinician Details
Clinician Name
Designation
Date
Clinician Signature / Authentication
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