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EYE EXAMINATION REPORT ATTENTION EYE CARE SPECIALIST: Your thoroughness in completing this report is essential for this child to receive appropriate early intervention services. Name ____________________________________ Sex M F Date of Birth ________________ Address ____________________________ City________________ State_______ Zip___________ Consent: I understand that this information will be used for developing and implementing intervention plans for my child and family. My consent covers any phone calls between IFSP/IEP staff and the physician. My consent is given voluntarily and is valid for up to three years from the date below. I understand that I may withdraw this consent at any time. Parent Signature ________________________________Date__________ Phone:______________ Return Completed form to: Anne Nielsen at 140 Bethany Drive in Manhattan, KS 66503. EYE EXAMINATION DATE ______________________ I. Ocular History (e.g., etiology, injuries, or operations). Age of onset _____________ History ___________________________________________________________________________ II. Measurements Visual Acuity -- If the acuity can be measured, complete this box using Snellen acuities or Snellen equivalents or NLP,LP, HM, CF, LB (legally blind) o With Glasses o Without Glasses Near Prescription Sph. Cyl. Axis Add Distance R (OD) Does this child/student meet the definition of cortical/neurological visual impairment? L (OS) Yes No B (OU) Is the child/student legally blind from a field restriction of 20 degrees or less? Yes No Is there a documented field loss? Explain _______________________________________________ Is there impaired color vision? Explain_________________________________________________ Is muscle function: _____ normal _____abnormal? Explain_______________________________ Are their contrast sensitivity issues: _____yes _____no? Was an optical device prescribed? Specify type and recommendations ________________________ _________________________________________________________________________________ III. Diagnosis. Primary cause of visual loss. If appropriate, indicate OD, OS, OU. Albinism Aniridia Astigmatism Aphakia Coloboma Congenital Cataracts Cataracts Prognosis: Stable Cortical Visual Impairment Delayed Visual Maturation Glaucoma Hyperopia ROP Stage _____________ RP Deteriorating Myopia _____ Nystagmus _____ Optic Atrophy _____ Optic Nerve Hypoplasia Strabismus Other: _________________ _________________________ Capable of improvement Uncertain Recommended Treatment: Glasses Patching Medication Surgery Low vision evaluation Other/Comments______________________________________ Glasses: Worn constantly Distance only Near only Sunglasses/tinted lenses Precautions or Suggestions: (e.g., lighting conditions, activities to be avoided, etc.) _____________ Next Recommended Eye Examination Appointment: _____________________________________ Name of Examiner (please print) ___________________________________ _____M.D. _____O.D. Signature of Examiner ______________________________ Date __________Phone________________ Questions or Concerns by or Referring Person: PLEASE ATTACH A COPY OF YOUR CHART NOTES FROM THE CHILD’S LAST EYE EXAMINATION APPT. IF GLASSES, PLEASE WRITE OUT THE PRESCRIPTION. THANK YOU! Physician’s Response