Farnsworth D15 Score Sheet Template

Name:___________________________________________ DOB:_______________________ Test Date:___________

Mode: Binocular__________ or OD _______ OS _______ Tester:_______________________

Binocluar Test 1 or OD Test 1 Binocluar Re-Test 1 or OD Test 1

3 4 3 4
5 5
2 6 2 6

1 1
AN

AN
DEUTAN

DEUTAN
7 7
PROT

PROT
Reference Cap Reference Cap

AN AN
TR IT TR IT
8 8

15 15
9 9

14 10 14 10

13 11 13 11
12 12

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