Seafarer Eye Examination Record Sheet
Name:
Rank/Position:
Date of Birth:
Date of Examination:
Vessel Name:
Nationality:
Visual Acuity
Test
Right Eye
Left Eye
Both Eyes
Unaided Distance
Aided Distance (with Glasses)
Near Vision
Color Vision Test
Test Used
Result
Remarks
Ocular Motility
Test
Findings
Eye Movements
Stereopsis
Other (specify)
Other Findings / Remarks
Examining Doctor's Name:
Signature:
Date: