Medical Referral For Students With Visual Impairments Page 2
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1
2
3CONFIDENTIAL
Eye Report for Children with Visual Problems
Name of Pupil: _________________________________________________________________ Sex: __________
(Type or Print)
(First)
(Middle)
(Last)
Address: _____________________________________________________________________ DOB: _________
(No. and Street)
(City or Town)
(State) (Zip)
Grade: ___________ School: _____________________ Address: ______________________________________
I. History
A. Probable age of onset of vision impairment: Right eye (O.D.) _____________ Left eye (O.S.) _______________
B. Severe ocular infections, injuries, operations, if any, with age at time of occurrence: _______________________
_________________________________________________________________________________________
C. Has pupil’s ocular condition occurred in any blood relatives? ______ If so, what relationship? _______________
II. Measurements (See next page for preferred notation for recording visual acuity table of approximate
equivalents
A. Visual acuity
Distant Vision
Near Vision
Prescription
Without
With best
With low
Without
With best
With low
Sph.
Cyl.
Axis
Correction
correction
vision aid
correction
correction
vision aid
Right eye (O.D.)
Left eye (O.S.)
Both eyes (O.U.)
Date: _______________
B. If glasses are to be worn, were safety lenses prescribed in: Plastic? ____________ Tempered glass? ________
C. If low vision aid is prescribed, specify type and recommendations for use: ______________________________
D. Field of Vision: Is there a limitation? _______ If yes, record results of test on next page.
E. What is the widest diameter (in degrees) of remaining visual field? O.D. __________ O.S. _____________
F. Is there impaired color perception? _______ If yes, for what colors? ___________________________________
III. Cause of Blindness or Vision Impairment
A. Present ocular condition(s) responsible for vision
O.D.______________________________________
impairment. (If more than one, specify all but underline the
O.S.______________________________________
one which probably causes severe vision impairment.
B. Preceding ocular condition, if any, which led to present
O.D.______________________________________
condition, or the underlined condition specified in A.
O.S.______________________________________
C. Etiology (underlying cause) of ocular condition primarily
O.D.______________________________________
responsible for vision impairment (e.g. specific disease,
O.S.______________________________________
injury, poisoning, heredity or other prenatal influence)
D. If etiology is injury or poisoning, indicate circumstances
O.D.______________________________________
and kind of poison or object involved.
O.S.______________________________________
VI. Prognosis and Recommendations
A. Is pupil’s vision impairment considered to be: Stable _____ Deteriorating _____ Capable of Improvement _____
Uncertain _____
B. What treatment is recommended, if any? ________________________________________________________
C. When is reexamination recommended? _________________________________________________________
D. Glasses: Not needed _____ To be worn constantly _____ For close work only _____ Other: ________________
Specify: _____________________________________________________________________________________
8/18/12
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