Download EYE EXAMINATION REPORT

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