Patient Problem Tracking Form for Optometrists Who Have Regular Business Relationships with Opticals

Patient:	_____________________________	Optician/OD_________________________
Original Rx Date:	_____________________	Date: ______________________________
Patient’s Reported Problem: 	 ______________________________________________________
	_____________________________________________________________________________
	_____________________________________________________________________________

			Previous Rx if available			New Rx
Rx age 	________________________________	_________________________

Doctor	________________________________	_________________________

Lens material	________________________________	_________________________

PD,CT,BC	________________________________	_________________________

Seg/Lens Type 	________________________________	_________________________

Seg Height	________________________________	_________________________

Coating	________________________________	_________________________

Frame Adjust	________________________________	_________________________

Decentration/Prism	____________________________	_________________________

Procedure	Complete	Performed	Comments	Date
	Yes or No	by

Adjustment	______	__________	_________________	______

Fabrication error/Rx remade	______	__________	_________________	______

New Rx Dispensed	______	__________	_________________	______

Pt not satisfied/Apt with Doctor	 ______	__________	_________________	______

Second exam findings	______	__________	_________________	______

New Rx dispensed with changes	______	__________	_________________	______

Doctor/Optician 2 week 	______	__________	_________________	______
Satisfaction call
Other	         			________________________________________________