Vision Screening Form - Livingston County Department Of Public Health

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Privacy Notice (04-14-03) given: __________
LIVINGSTON COUNTY DEPARTMENT OF PUBLIC HEALTH
2300 E. Grand River Ave., Suite 102 • Howell, MI 48843-7578 • (517) 546-9850
Screening Location: __________________________________________ School District: ___________________________
Child’s Legal Name: _______________________________________________ Birthdate: _____________ Age: ________
Parent/Guardian’s Name: ____________________________________ Phone Number: ____________________________
Address: ____________________________________________ City: _______________________, MI Zip: ____________
Medicaid: (please circle) Yes
No
If yes, Dr.’s Name ______________________________________________________
Dr.’s Address/City ________________________________________________
(If child has Medicaid, and is 3-6 yrs old,
Dr.’s Phone: _____________________________
results will be forwarded to child’s Doctor.)
BRIEF HEARING HISTORY
BRIEF EYE HISTORY
1. Does your child have a programmable shunt? Yes No
1. Has your child ever been examined by an eye doctor?
2. Has child been seen by a doctor for any ear problems?
Yes
No
If yes, when? _______________________
Yes
No
If yes, when? _______________________
Reason: ______________________________________
Reason:______________________________________
Name of Eye Doctor: ____________________________
Name of Doctor: _______________________________
2. As a parent/guardian, do you have concerns regarding
3. As a parent/guardian, do you have concerns regarding
your child’s vision?
Yes
No
your child’s hearing?
Yes
No
If yes, please describe: __________________________
If yes, please describe: _________________________
3. When your child is ill or tired, do his/her eyes appear
_____________________________________________
crossed or does one eye wander when looking at an
4. Is child currently on medication for cold/allergies?
object?
Yes
No
Yes
No
If yes, name of medication: ___________
(If your child confuses colors or a family member has a
____________________________________________
Color Vision Deficiency, please discuss with your child’s
doctor. The vision screening performed does not check
for Color Vision Deficiency.)
-- PLEASE DO NOT WRITE BELOW THIS LINE --
HEARING SCREENING RESULTS:
VISUAL ACUITY – LEA SYMBOLS CARDS
1.
___ Pass Preliminary Screen
20/40
Both Eyes
0 1 2 3
4 5 6
*(20/50)*
Right Eye
0 1 2 3
4 5 6
R -
___ Pass Intermediate Sweep
Left Eye
0 1 2 3
4 5 6
L -
___ Did not Pass – To be Rescreened
20/25
Right Eye
0 1 2 3
4 5 6
Tones Missed: ________________________
Left Eye
0 1 2 3
4 5 6
Date of Rscrn Appt: ____________________
2. STEREO BUTTERFLY TEST - Near:
PASS
FAIL
___ Unable to Screen/Complete Screen
EYE HISTORY
3.
PASS
FAIL
___ Audiogram
(See audiogram for details)
SYMPTOM REFERRAL
___
Pass
4.
PASS
FAIL
___
Refer
A
N
P
S
W
N/A
___
Other (Under Care/Known Loss)
VISION SCREENING RESULTS:
___ Pass
Rx: Glasses
Contacts
N/A
Comments: ___________________________________
___
Refer on: _______________________________
_____________________________________________
___
Under Care
___ Permanent Difficulty
___
Unable to Screen/Complete Screen
Technician: ___________________________________
Comments: _______________________________________
Date of Screening: _____________________________
Technician: _________________________ Date: _________
Gd S:\V&H\H&V Originals\Forms\H&V Screen Form 06-19-15.doc

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