ISHIHARA COLOR VISION RECORDING FORM
PATIENT NAME:
SEX:
AGE:
EXAM DATE:
LIGHT CONDITION:
EXAMINER:
TEST DETAILS:
| Plate No. | Expected Answer | Patient Response | Correct? | Notes | R/G Deficiencies | Total Color Blindness | |
|---|---|---|---|---|---|---|---|
| Protan / Deutan | Mild / Strong | ||||||
Interpretation Summary
Total Correct Plates: 0 / 24
OPHTHALMOLOGY / OPTOMETRY
PRC LIC. NO. / SIGNATURE
Printed: 08/17/2026 03:48 PM