State Of Illinois Eye Examination Report Form (Page 2 of 2) in pdf

State Of Illinois Eye Examination Report Form Page 2

State of Illinois

Eye Examination Report

Illinois Department of Public Health

Recommendations

1. Corrective lenses:

q No

q Yes, glasses or contacts should be worn for:

q Constant wear

q Near vision

q Far vision

q May be removed for physical education

2. Preferential seating recommended:

q No

q Yes

Comments _____________________________________________________________________________________

______________________________________________________________________________________________

3. Recommend re-examination:

q 3 months

q 6 months

q 12 months

q Other ____________________________________

4. ______________________________________________________________________________________________

5. ______________________________________________________________________________________________

Print name _______________________________________

License Number ________________________________

Optometrist or physician (such as an ophthalmologist)

who provided the eye examination q MD q OD q DO

Consent of Parent or Guardian

I agree to release the above information on my child

or ward to appropriate school or health authorities.

Address

________________________________________

(Parent or Guardian’s Signature)

(Date)

Phone

________________________________________

Signature ________________________________________

Date ___________________

(Source: Amended at 32 Ill. Reg. _________, effective ___________)

Page 2

Printed by Authority of the State of Illinois

IOCI 15-391

State Of Illinois Eye Examination Report Form Page 2