Ishihara Color Vision Recording Form

Name:

Sex:

Age:

Exam Date:

Light Condition:

Examiner:

Test Details:

24-Plate 38-Plate Others:

Plate No.	Expected Answer	Patient Response	Correct?	Notes	R/G Deficiencies		Total Color Blindness
Plate No.	Expected Answer	Patient Response	Correct?	Notes	Protan / Deutan	Mild / Strong	Total Color Blindness

Total Correct Plates: 0 / 24

Primary Finding:

Red/green deficiency

Protan Mild Moderate Severe

Deutan Mild Moderate Severe

Remarks

OPHTHALMOLOGY / OPTOMETRY

PRC LIC. NO. / SIGNATURE

Printed:

Ishihara Recording System