Medical Referral For Students With Visual Impairments Page 3
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3E. Lighting Requirements: Average _____ Better than average _____ Less than average _____
F. Use of eyes: Unlimited _____ Limited, as follows: __________________________________________________
Physical Activity: Unrestricted _____ Restricted, as follows: __________________________________________
To be forwarded by Examiner to:
Signature of Examiner: _____________________________ Degree: _______________ Date of Exam: _________
Address: ____________________________________________________________________________________
If clinic care: Number: ____________________ Name of Clinic: ________________________________________
Preferred Vision Acuity Notations
Distant Vision. Use Snellen notation with test distance of 20 feet. (Examples: 20/100, 20/60). For acuities less than 20/200
record distance of which 200 foot letter can be recognized as numerator of fraction and 200 as denominator. (Examples: 10/200,
3/200). If the 200 foot letter is not recognized as 1 foot, record abbreviation for best distant vision as follows:
HM
Hand Movements (Specify inches or feet)
PLL
Perceives And Localizes Light in one or more quadrants
LP
Perceives But Does not Localize Light
NoLP
No Light Perception
Near Vision. Use standard A.M.A. notation and specify best distance at which pupil can read. (Example: 14/70 at 5 in.)
Table of Approximate Equivalent Visual Acuity Notations
These notations serve only as an indication of the approximate relationship between recording of distant and near vision and
point type sizes. The teacher will find in practice that the pupil’s reading performance may vary considerably from the
equivalents shown.
Near
% Central Visual
Distant Snellen
A.M.A.
Jeager
Metric
Efficiency for Near
Point
Usual Types of Text Size
20/20 (ft)
14/14 (in)
1
0.37 (M)
100
3
Mail Order Catalog
20/30
14/21
2
0.50
95
5
Want Ads
20/40
14/28
4
0.75
90
6
Telephone Directory
20/50
14/35
6
0.87
50
8
Newspaper Text
20/60
14/42
8
1.00
40
9
Adult Text Books
20/80
14/56
10
1.50
20
12
Children’s Books 9-12 yrs
20/100
14/70
11
1.75
15
14
Children’s Books 8-9 yrs.
20/120
14/84
12
2.00
10
18
Large type text
20/200
14/140
17
3.50
2
24
Large type text
12.5/200
14/224
19
6.00
1.5
8/200
14/336
20
1
5/200
14/560
3/200
14/900
Field of Vision. Record results on chart below.
Type of Test used: _____________________________ Illumination in ft. candles: ___________________________________
8/18/12
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