Download Interagency Eye Examination Report (DARS2006-E)

DARS2006-E
09-2004
State of Texas
INTERAGENCY
EYE EXAMINATION REPORT
As mandated by Texas law (Senate Bill, 959), this form must not contain information about the
presence of HIV testing or testing results. (See Attachment). tab
Patient's Name:
Date of Birth:
Social Security No.:
Address:
City:
State:
Zip:
Attention Eye Care Specialist
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 tab to next cell
If the acuity can be measured, complete the boxes below using Snellen acuities or Snellen
equivalents or NLP, LP, HM, CF. tab to next cell
Without glasses: Near Right:
Near Left:
Distance Right:
Distance Left:
With Best
Near Right:
Near Left:
Distance Right:
Distance Left:
Correction:
Acuity with glare testing, if applicable tab Right:
Left:
If the acuity cannot be measured, indicate below the most appropriate estimation. tab to next cell
Legally Blind:
Not Legally Blind:
Muscle Function
Normal:
Abnormal:
Intraocular Pressure Reading tab
Describe:
Right:
Left:
Visual Field Test tab to next cell
There is no apparent restriction:
There is a field restriction, Describe:
The visual field is restricted to 20 degrees or less
Color Vision
Normal
Abnormal
Yes:
Photophobia
No:
Yes
No
tab
Diagnosis (Primary cause of visual loss):
Prognosis:
Permanent:
Recurrent:
Improving:
Progressive:
Communicable:
Can Be Improved:
Treatment Recommended
Glasses
Patches
Surgery
Number of days needed for Hospitalization
Right
Left
Name of hospital:
Name of anesthesiologist or group:
Medication:
Refer for other medical treatment/exam:
Low Vision Evaluation
Other
Precautions or Suggestions (e.g., lighting conditions, activities to be avoided, etc.):
Scheduling
Date of Next Appointment:
Time:
IMPORTANT, Check the most appropriate statement.
This patient appears to have no vision.
This patient has a serious visual loss after correction.
This patient does not have a serious visual loss after correction.
Print or Type Name of Licensed Ophthalmologist or Optometrist
Signature of Licensed Ophthalmologist or Optometrist
Address:
Date of Examination:
City:
State:
Zip:
Telephone Number:
RETURN COMPLETED FORM TO:
Name:
Address: 4800 N. Lamar Blvd., Suite #:
Agency: Department of Assistive and
Rehabilitative Services – DIVISION FOR
City: Austin
State: TX
Zip:78756
BLIND SERVICES
This form should be used when an ophthalmological/optometric examination is needed for (the): DARS
Division for Blind Services - School Districts - Special Education Programs - Regional Education Service
Centers (ESCs) - Early Childhood Programs (ECH) - Early Childhood Intervention Programs (ECI) - Texas
School for the Blind and Visually Impaired (TSBVI) - Eye Screening Follow-Up Examinations - Texas
Department of Health (TDH) - Texas Department of Mental Health/Mental Retardation (TDMHMR).
This is the end of the form. Press Ctrl + Home to return to the top or Shift + Tab to move backwards.
CONFIDENTIAL
Attachment to General Eye Exam
As covered by Senate Bill 959, this attachment should be used to report the presence of HIV testing
and the test results. Complete this attachment only with the patient's informed, written consent. This
information will be maintained in a secure file by the DARS Division for Blind Services.
Diagnosis:
Prognosis:
Medications:
Physician Name:
Date:
STATEMENT OF RELEASE
I authorize release of information related to HIV testing to: (specify individual(s) or classes of
individuals)
for the purpose of effective planning of services and case decisions.
Applicant/Client:
Date:
CONFIDENTIAL
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