Ohts Etdrs V/a Worksheet: Chart R Eye Examination Form
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1OHTS ETDRS V/A Worksheet: Chart R
Page 1 of 1
10/04/94
OHVR02.01
Patient ID:
/
/
Visit Date:
mm
dd
yy
For Clinic use only
Do not send to Coordinating Center
Visual Acuity Testing Distance in Meters (Circle):
4.0m
3.2m
2.5m
2.0m
Circle each letter the participant identifies correctly, put an “x” or line through each letter incorrectly or omitted
and write the total correct for that row in column at right. Enter 0 if no letters are read correctly. Each row total
must be entered.
Line
Right Eye
Left Eye
Number
Number
Correct
Correct
1.
H V Z D S
H V Z D S
2.
N C V K D
N C V K D
3.
C Z S H N
C Z S H N
4.
O N V S R
O N V S R
5.
K D N R O
K D N R O
6.
Z K C S V
Z K C S V
7.
D V O H C
D V O H C
8.
O H V C K
O H V C K
9.
H Z C K O
H Z C K O
10.
N C K H D
N C K H D
11.
Z H C S R
Z H C S R
12.
S Z R D N
S Z R D N
13.
H C D R O
H C D R O
14.
R D O S N
R D O S N
Total number correct for right eye
Total number correct for left eye
After completion of testing for both eyes, enter total number correct for each eye and testing distance in
REDCap.
Investigator’s Certification:
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