IDPS - The Eye Lady

IDPS Diagnostic Scoring Sheet — The Eye Lady

Client Details

Name

Date of Birth

Age

Phone

Address

Email

School / Workplace

Year / Grade

Parent / Guardian Name

Screener

Visual Assessment Date

Optometrist

Optical Prescription (Opt Rx)

Assessment Type

First Time Tint Assessment Recheck

Last Tint

Printed Page

✓

Problem corrected

O

Partial correction

✗

No improvement

#	Question	Notes	Yes?	1–2 tints	3+ tints

Comments / Observations

Eye Chart

✓

Problem corrected

O

Partial correction

✗

No improvement

#	Question	Notes	Yes?	1–2 tints	3+ tints

Acuity Measurements

Without Filters

Near

Distance

Contrast

With Filters

Near

Distance

Contrast

Comments

Outcome & Results

Improvement with Filters

Best Filter Combination

Recall

12 months 24 months

Comments

Diagnostician

Name

Credentials / Title