Download Vision Eye Exam Report

(Insert District Logo/Information Here)
Patient’s Name:
_____ D.O.B.:
Address:
City:
____
SASID Number:
State:
______
Zip:
Attention Eye Care Specialist:
Please address each item below.
Your thoroughness in completing this report is essential for this patient to receive appropriate services.
Ocular History (e.g., previous eye diseases, injuries, or operations)
Age of Onset ___________
History _________________________________________________________________
__________________________________________________________________________________________
Visual Acuity
If the acuity can be measured, complete this box using
Snellen acuities or Snellen equivalents or NLP, LP, HM, CF.
Without Glasses
With Best Correction
Near
Distance
Near
Distance
OD
OD
OD
OD
Acuity with glare testing, if applicable:
OS
OS
OS
OS
OD_________
OU
OU
OU
OU
OS _________
IMPORTANT: If the acuity cannot be measured, check the appropriate estimation.
Functions better than 20/200 corrected, in his/her best eye (Snellen equivalent)
Meets the definition of Blindness “MDB” Central vision acuity of 20/200 or less in the better eye with correcting glasses or a peripheral
field so contracted that the widest diameter of such field subtends an angular distance no greater than 20 degrees.
Functions at the definition of Blindness “FDB” When visual performance is reduced by a brain injury or dysfunction when visual
function meets the definition of blindness as determined by an eye care specialist or neurologist. Students in this category manifest unique visual characteristics often
found in conditions referred to as neurological, cortical or cerebral vision impairment.
Muscle Function
Normal
Intraocular Pressure Reading
Abnormal
Describe:
OD _______________ OS ______________
Visual Field Test
There is no apparent visual field restriction.
There is a field restriction. Describe __________________________________________
Yes
No
The visual field is restricted to 20 degrees or less.
Color Vision
Normal
Abnormal
Photophobia
Yes
No
Diagnosis (Primary cause of visual loss)
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
Permanent
Recurrent
Improving
Progressive
Communicable
Can Be Improved
Treatment Recommended
Glasses
Prescription OD ___________________
Patches (Schedule):
OS ___________________
OD ______________________________
Medication _______________________
OS ______________________________
Low Vision Evaluation
Refer for other medical treatment/exam:
Other ____________________________
_________________________________
Scheduling
Date of Next Appointment ___________________ Time _____________
Precautions or Suggestions (e.g., lighting conditions, activities to be avoided, etc.)
__________________________________________________________________________________________________
____________________________________________
Print or Type Name of Licensed Ophthalmologist or Optometrist
____________________________________________
Address
___________________________________________
Date of Examination
____________________________________________
City
____________________________________________
Signature of Licensed Ophthalmologist or Optometrist
State
Zip
____________________________________________
Telephone Number
RETURN COMPLETED FORM TO:
_______________________________________________
Name
_______________________________________________
Address
_______________________________________________
Agency
_______________________________________________
City
State
Zip