CL Checklist OWNDAYS MY

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

EYE HEALTH CHECK

Hygiene

• Over all

  Pass

  Fail

• Using alcohol spray before touching customer

  Pass

  Fail

• Slit lamp set up

  Pass

  Fail

• Lids & Lashes

  Select Slit width Brightness Magnification Angle Identify Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Identify
  • Fail

• Bulbar Conjunctiva

  Select Slit width Brightness Magnification Angle Identify Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Identify
  • Fail

• Palpebral Conjunctiva

  Select Slit width Brightness Magnification Angle Identify Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Identify
  • Fail

• Limbus

  Select Slit width Brightness Magnification Angle Identify Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Identify
  • Fail

• Iris

  Select Slit width Brightness Magnification Angle Identify Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Identify
  • Fail

• Cornea

  Select Slit width Brightness Magnification Angle Identify Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Identify
  • Fail

• Tears

  Select Slit width Brightness Magnification Angle Identify Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Identify
  • Fail

• Crystalline Lens

  Select Slit width Brightness Magnification Angle Identify Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Identify
  • Fail

• Manners while processing on customers

  Pass

  Fail

FITTING CHECK

• Comfort

  Pass

  Fail

• Coverage

  Select Slit width Brightness Magnification Angle Evaluation Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Evaluation
  • Fail

• Centration

  Select Slit width Brightness Magnification Angle Evaluation Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Evaluation
  • Fail

Lag-Sag

• Primary gaze

  Select Slit width Brightness Magnification Angle Evaluation Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Evaluation
  • Fail

• Up gaze

  Select Slit width Brightness Magnification Angle Evaluation Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Evaluation
  • Fail

• Lateral gaze

  Select Slit width Brightness Magnification Angle Evaluation Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Evaluation
  • Fail

• Movement

  Select Slit width Brightness Magnification Angle Evaluation Fail

  • Slit width
  • Brightness
  • Magnification
  • Angle
  • Evaluation
  • Fail

PRODUCT INFORMATION

INFORMATION OF CLEAR CONTACT LENS

• Product price of clear contact lens (Monthly/Daily)

  Pass

  Fail

• Water content (38%)

  Pass

  Fail

• Diameter (14mm.)

  Pass

  Fail

• Thickness of center (0.06mm)

  Pass

  Fail

• Material (Polymacon)

  Pass

  Fail

• Power range

  Pass

  Fail

• DK (13.5)

  Pass

  Fail

• Key features of Clear contact lens

  Select Natural moisturizing UV Protection Comfort care Fail

  • Natural moisturizing
  • UV Protection
  • Comfort care
  • Fail

• Contact lens care (explain)

  Good

  Fair

  Poor

• Instruction for do and don't

  Select 6 5 4 3 2 1 0

  • 6
  • 5
  • 4
  • 3
  • 2
  • 1
  • 0

Signature

• Trainee

  Sign

• Trainer

  Sign

• Manager

  Sign