OptiAI
Rx
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OptiAI
Rx
Lens Hut
Rx
Right OD
—
Left OS
—
Add
—
Idx
—
✚ New Patient
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History
📋 History
🕶 Existing & VA
🎯 Lifestyle
💬 Complaints
Testing
🔦 Colour
🔬 Refraction
👀 BV
⚙️ Accom
Final
✅ Final
Case History
Req
Name
*
Age
*
Phone Number
*
Occupation
Medical Professional / Chef (mask or heat-exposure occupation)?
Not_assessed
No
Yes
Task priority
*
Select
Distance dominant
Intermediate dominant
Near dominant
Distance-Intermediate
Intermediate-Near
Mixed
Computer hours
*
-
None
1-3 hrs
4-6 hrs
7+ hrs
Reading hours
*
-
None
1-3 hrs
4-6 hrs
7+ hrs
Focused work hours
*
-
None
1-3 hrs
4-6 hrs
7+ hrs
Office user hours
-
None
1-3 hrs
4-6 hrs
7+ hrs
Profession / Primary Work Type
Select
Architecture / Engineering / CAD
Banking / Finance / Insurance
Client Service / Consultation Desk
Design / Styling / Precision Work
Driving / Field Work
Healthcare / Clinical
Home / Household
Laboratory / Research
Management / Meetings
Office / Computer / IT
Reading / Writing / Administration
Retail / Customer Service
Retired / Leisure-focused
Teaching / Training
Other
Does the patient need to see people or screens across a room — meetings, teaching, presentations?
*
Select
Yes
No
Chief complaint
*
Chief complaint severity
*
Select
None
Mild
Moderate
Severe
Driving
Select
None
Day only
Day & night
First-time wearer?
*
Select
First-time wearer
Existing wearer
Previous lens
*
Select
None
Single vision
Office lens
Bifocal
PAL
Adaptation
*
Select
None
Mild
Moderate – struggled
Severe – refused PAL
Expectation
*
Select
Basic
All-day comfort
Premium
Ocular history (select all that apply)
*
Systemic health
*
Symptom onset
Select
Sudden (days)
Recent (weeks)
Gradual (months)
Long-standing (years)
Last eye exam
Select
<1 yr
1–2 yrs
>2 yrs
Never / unsure
Ocular-risk medication
Select
None
On ocular-risk med (hydroxychloroquine / long-term steroids)
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Phone Number
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Behaviour Score
Req
Total
0/27
Working Distances (cm)
Phone
Laptop
Dashboard
Counter
Active Complaints
All categories required
Existing RX
Req
Frame
Select
Good
Fair
Poor
None
Lens
Select
Good
Scratched
Coating worn
Stability
Not assessed
Stable
Slipping
Tilted
Old Rx
Sph
Cyl
Ax
Add
Right OD
Left OS
Complaint reproduced with current glasses?
Not_assessable
Yes - persists with current glasses
Partially
No
Visual Acuity
Req
Test
Right OD
Left OS
Status
Distance VA Unaided
*
Select
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60
Select
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60
Select
Full
Partial
Near VA Unaided
*
Select
N6
N8
N10
N12
N18
N24
N36
N48
Select
N6
N8
N10
N12
N18
N24
N36
N48
Select
Full
Partial
Distance VA With Current Glasses
*
Select
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60
Select
6/5
6/6
6/9
6/12
6/18
6/24
6/36
6/60
Select
Full
Partial
Near VA with Current Lenses
*
Select
N6
N8
N10
N12
N18
N24
N36
N48
Select
N6
N8
N10
N12
N18
N24
N36
N48
Select
Full
Partial
Intermediate VA with Current Lenses
Select
Full
Partial
Distance VA Pinhole
*
Select
6/6
6/9
6/12
6/18
6/24
6/36
6/60
Select
6/6
6/9
6/12
6/18
6/24
6/36
6/60
Select
Full
Partial
Pinhole Right OD
*
Not tested
Improved with pinhole
No improvement with pinhole — further evaluation advised
Partial improvement — refractive error with possible additional ocular factor
Pinhole Left OS
*
Not tested
Improved with pinhole
No improvement with pinhole — further evaluation advised
Partial improvement — refractive error with possible additional ocular factor
Confrontation fields
*
Not tested
Full
Defect – refer
Colour & Torch
Req
Ishihara — plates correct
Ishihara — plates shown
Select
14
17
24
38
Not tested
Colour defect onset
Select
Congenital (lifelong)
Acquired (new / recent) – refer
Not known
Not tested
Ishihara — staff interpretation
Not assessed
PASS
FAIL
INCONCLUSIVE
RAPD
*
Select
Normal
RAPD R
RAPD L
Not testable
Amsler
*
Select
Normal
Distortion – refer
Missing lines – refer
Not testable
Tear film
Not tested
Normal
Mild dry-eye
Mod/severe
Blink
Not obs
Normal
Reduced
Torch
Select
Normal
Refer
Not testable
Light Sensitivity questionnaire (10–100)
—
10 low
10
100 high
Photophobia specifically reported / identified?
Not_assessed
No
Yes
Light sensitive concern during travel?
Not_assessed
No
Yes
Binocular Vision
BV
EOM (eye movements)
Not tested
Full
Restricted – refer
Cover test dist
*
Not tested
Ortho
Exophoria
Esophoria
Exotropia
Esotropia
Hypertropia
Hypotropia
Hyperphoria
Hypophoria
Refer
Not testable
Cover test near
*
Not tested
Ortho
Exophoria
Esophoria
Exotropia
Esotropia
Hypertropia
Hypotropia
Hyperphoria
Hypophoria
Refer
Not testable
NPC (RAF Ruler)
Worth 4 Dot
*
Not tested
Fusion
Suppression R
Suppression L
Diplopia – urgent
Stereopsis
Not tested
Normal
Reduced
Poor
Absent
Fus reserves
Not tested
Normal
Reduced BO
Reduced BI
Maddox dist
Maddox near
Maddox vertical
Prism req
Not assessed
No
Yes – prescribe
Yes – refer
Prism OD magnitude
Prism OD base
Select
BI
BO
BU
BD
Prism OS magnitude
Prism OS base
Select
BI
BO
BU
BD
Refraction
Req
Subjective Rx
*
(all fields required)
Sph
Cyl
Ax
Dist VA
Add
Near VA
Right OD
Left OS
Duochrome
Not assessed
Balanced
Red clearer
Green clearer
Bino balance
Not assessed
Balanced
R dominant
L dominant
JCC
Not assessed
Stable
Fluctuating
Post-refraction tests (with final Rx in place)
Glare
Not tested
Normal
Mild drop
Significant
Contrast (Pelli-Robson)
*
Not tested
Normal (≥1.65 log)
Mildly reduced (1.35–1.60)
Moderately reduced (1.05–1.30)
Significantly reduced (<1.05)
Not testable
Dominant eye
Not tested
Right
Left
Accommodation
Adv
NPA / Amplitude (RAF Ruler)
NRA
PRA
Flipper
Not tested
Normal
Low monocular
Low binocular
Near-far rock
Not tested
Smooth <3 sec
Delayed >3 sec
Poor – unable to clear – refer
Not testable
Pre-presbyopic symptoms
Notes
Final Validation
Req
Distance
Select
Clear & comfortable
Slightly blurred
Uncomfortable
Near
Select
Clear & comfortable
Slightly blurred
Uncomfortable
Intermediate
Select
Clear & comfortable
Slightly blurred
Uncomfortable
Comments
Staff sign-off
*
Pending
Reviewed & confirmed
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