Attach_7_Eye_Exam_Laser_Use.doc

Attachment 7 Eye Exam for Laser Use

The NIOSH-Morgantown Laser Safety Program requires personnel who work with Class 3b and Class 4 lasers to have a baseline ocular examination. This requirement is consistent with the recommendations in ANSI Z136.1, Safe Use of Lasers. The purpose of these eye exams is to establish a baseline in the event of an accidental injury and to identify certain workers who might be a special risk.

Patient: Please complete sections 1 and 2.

Section 1: Patient Information

Name

Address

Telephone

DOB

□ Male □ Female

Emergency Contact

Phone

1. Do you require corrective vision □ No

□ Yes

If yes, age of current glasses contacts

Do you wear glasses?

□ No

Worn: □ Always

□ Distance Only

□ Reading Only

Do you wear contact?

□ No

Average wearing time per day?

2. Reason for exam:

□ Pre-Placement Exam □ Post-Incident Exam □ Exit Exam

Section 2: Medical History

Examination Date:

Chief Complaint (if any)

Date of last eye exam:

Personal Health History

Have you had any problems with your eyes in the past?

□ No

If yes, when

Please describe the problem:

Have you had any of the following serious illnesses?

□ Cancer

□ Diabetes

□ High Blood Pressure

□ Heart Disease

□ Glaucoma

□ Cataracts

□ Other eye-related diseases

Are you currently under medical care for any chronic or long-term illnesses?

/ Medication

/ Medication

Do you smoke?

□ Yes

Medications/Allergies Are you taking any medications/supplements □ No

□ Yes

Are you allergic to any medications?

□ No

Other allergies

Family History

Have any of your (close) blood relatives had any of the following serious illnesses?

□ Cancer

□ Diabetes

□ High Blood Pressure

□ Heart Disease

□ Glaucoma

□ Cataracts

□ Other eye-related diseases

Section 3: Required Procedures

1. Visual Acuity

□ WITH / □ WITHOUT

Eye Glasses or Contact Lenses

Distance

OD 20/

OS 20/

Near

OD 20/

OS 20/

Current glasses

OD

OS

2. Macular Function (Amsler Grid)

NORMAL / ABNORMAL

3. Color Vision

Method D-15

100 Hue other (circle one)

Result

4. Fundoscopy (with pupil dilation)

Optic Nerve

Maculae

Periphery

5. Summary

Binocular Vision

Anterior Segment Anomalies

Please list cause, if applicable:

Vision decrease

Amsler Grid anomaly

Color Vision defect

Any other anomalies noted

Assessment/Additional Notes:

□ At this time, additional testing for suitability to work with lasers is not indicated.

□ I recommend additional testing to adequately assess a special risk or particular eye condition.

□ Contrast Sensitivity Testing □ Macular Photostress

□ Retinal Photography

□ OD □ MD

Printed Name of Examining Eye Care Professional

Signature

Date If any of the baseline tests show an abnormal ocular function that could be affected by work with lasers, the examining eye care professional may order supplemental testing to ensure an adequate eye health assessment.

Section 4: Supplemental Eye Exam for Laser Users

Patient Name:

(please print)

Standard Baseline Eye Exam, given on this date

, is attached

a. Contrast Sensitivity Testing

b. Macular Photostress

(in seconds to recover 1 line above max V.A.)

c. Retinal Photographs

□ 35 mm

□ Polaroid

□ Other

Notes:

Summary/Notes/Recommendations

□ OD □ MD

Printed Name of Examining Eye Care Professional

Signature

Date