Vision Screening / Referral Form
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1Vision Screening & Referral Form
School Nurse Name: ____________________________
Student Name: ________________________________________
Phone # ______________________________________
DOB: _____________________ Grade: _____________________
Fax# _________________________________________
School: _______________________ Fax#___________________
Dear Provider:
Below are the results of the school vision screening on the student named above.
Please complete the Eye Care Specialist Report and return the completed form
to the school nurse listed above. A request is also made that you provide the
parent/guardian with a copy of the report.
School Screening Report
st
nd
1
Date screened
□ With
□ Without
2
Date Screened
□ With
□ Without
_______________
correction
correction
_________________
correction
correction
Distance Visual Acuity:
Distance Visual Acuity:
R 20/_____
L 20/_____
R 20/_____
L 20/_____
Ocular Alignment
Color Vision
Clinical Observation Notes
(Random Dot E/Stereotest)
□ Pass
□ Pass
□ Fail
□ Fail
□ Did Not Test
□ Did Not Test
Eye Care Specialist Report
Date of Exam:
Overall Findings:
□ Strabismus
□ Normal exam, no glasses needed
□ Amblyopia
□ Significant refractive error, glasses needed
□ Other (please specify):________________
Distance Visual Acuity:
Without Correction
With Current Prescription
With New Prescription
R_________ L_________
R_________ L_________
R_________ L_________
Cycloplegic refraction is recommended for all children.
□
□
□
□
□
Was a prescription for glasses given?
Agent used:
Cyclopentolate
Tropicamide
None
Yes
No
Cycloplegic Refraction
Vision
Glasses Prescription Given
Sphere
Cylinder
Axis
Sphere
Cylinder
Axis
OD
OS
Do you need to see this child again? _________
When?_______________________________
Recommendations (other than glasses):
□ Patching
□ Atropine drops
□ Referral to pediatric specialist
□ Other (specify):_______________________________
Eye Specialist: ______________________________________________
Date: _____________________________________
Office Phone Number: _____________________________ Office Address: __________________________________________
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