State Of Illinois Eye Examination Report Form

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State of Illinois
State of Illinois
Eye Examination Report
Illinois Department of Public Health
Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who pro-
vides eye examinations be submitted to the school no later than October 15 of the year the child is first enrolled or as re-
quired by the school for other children. The examination must be completed within one year prior to the first day of the
school year the child enters the Illinois school system for the first time. The parent of any child who is unable to obtain an
examination must submit a waiver form to the school.
Student Name _____________________________________________________________________________________
(Last)
(First)
(Middle Initial)
Birth Date _________________
Gender ______ Grade ______
(Month/Day/Year)
Parent or Guardian _________________________________________________________________________________
(Last)
(First)
Phone___________________________
(Area Code)
Address __________________________________________________________________________________________
(Number)
(Street)
(City)
(ZIP Code)
County _______________________________________
To Be Completed By Examining Doctor
Case History
Date of exam ________________
Ocular history:
q Normal
or Positive for ___________________________________________________________
Medical history:
q Normal
or Positive for ___________________________________________________________
Drug allergies:
q NKDA
or Allergic to ____________________________________________________________
Other information ___________________________________________________________________________________
Examination
Distance
Near
Right
Left
Both
Both
Uncorrected visual acuity
20/
20/
20/
20/
Best corrected visual acuity 20/
20/
20/
20/
Was refraction performed with dilation? q Yes q No
Normal
Abnormal
Not Able to Assess
Comments
External exam (lids, lashes, cornea, etc.)
__________
q
q
q
Internal exam (vitreous, lens, fundus, etc.)
__________
q
q
q
Pupillary reflex (pupils)
__________
q
q
q
Binocular function (stereopsis)
__________
q
q
q
Accommodation and vergence
__________
q
q
q
Color vision
__________
q
q
q
Glaucoma evaluation
__________
q
q
q
Oculomotor assessment
__________
q
q
q
Other _________________________
__________
q
q
q
NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.
Diagnosis
q Normal
q Myopia
q Hyperopia
q Astigmatism
q Strabismus
q Amblyopia
Other ____________________________________________________________________________________________
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