OPHTHALMOLOGY EXAMINATION REPORT
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Applicant’s details Medical in Confidence
(1) State applied to: (2) Medical certificate applied for Class: 1 2 3 AFS/FIS
(3) Surname: (4) Previous surname(s): (12) Application:
Initial
Renewal/Revalidation
(5) Forename(s): (6) Date of birth: (7) Sex: (13) Reference number:
Male
Female
(301) Consent to release of medical information:
I hereby authorise the release of all information contained in this report and any or all attachments to the AME and, where necessary, to the medical assessor of
the licensing authority, recognising that these documents or any other electronically stored data are to be used for completion of a medical assessment and will
become and remain the property of the licensing authority, providing that I or my physician may have access to them according to national law. Medical
confidentiality will be respected at all times.
………………………… ………………………………………………… ………………………………………………………
Date Signature of the applicant Signature of AME
(302) Examination Category: (303) Ophthalmological history:
Initial
Revalidation
Renewal Special referral
Clinical examination: Visual acuity:
Check each item Normal Abnormal (314) Distant vision (at 5m/6m)
Uncorrected Spectacles Contact lenses
(304) Eyes, external & eyelids
Right eye Corrected to
(305) Eyes, Exterior (slit lamp, ophth.) Left eye Corrected to
Both eyes Corrected to
(306) Eye position and movements
(315) Intermediate vision (at 1 m)
(307) Visual fields (confrontation) Uncorrected Spectacles Contact lenses
(308) Pupillary reflexes Right eye Corrected to
Left eye Corrected to
(309) Fundi (Ophthalmoscopy) Both eyes Corrected to
(310) Convergence cm
(316) Near vision (at 30-50 cm)
(311) Accomodation D Uncorrected Spectacles Contact lenses
Right eye Corrected to
Left eye Corrected to
(312) Ocular muscle balance (in prisme dioptres) Both eyes Corrected to
Distant at 5/6 meters Near at 30-50 cm
Ortho Ortho (317) Refraction Sph Cylinder Axis Near (add)
Eso Eso Right eye
Exo Exo Left eye
Hyper Hyper Actual refraction examined Spectacles prescription based
Cyclo Cyclo
Tropia Yes No Phoria Yes No
(318) Spectacles (319) Contact lenses
Fusional reserve testing Not performed Normal Abnormal
Yes No Yes No
Type: Type:
(313) Colour perception
Pseudo-Isochromatic plates Type: Ishihara (24 plates)
No of plates: No of errors: (320) Intra-ocular pressure
Advanced colour perception testing indicated Right (mmHg) Left (mmHg)
Yes No
Method: Method:
Colour SAFE Colour UNSAFE Normal Abnormal
(321) Ophthalmological remarks and recommendation:
(322) Examiner's declaration:
I hereby certify that I/my AME group have personally examined the applicant named on this medical examination report and that this report with any attachment embodies my findings
completely and correctly.
(323) Place and date: Opht examiner's name and address: (Block Capitals) AME or specialist stamp No:
AME signature:
E-mail:
Telephone No:
Telefax No:
EASA OPHTHALMOLOGY EXAMINATION REPORT FORM – Feb. 2014