State Of Illinois Eye Examination Report
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1State of Illinois
Eye Examination Report
Illinois law requires that proof of an eye examination by an optometrist or physician who provides complete eye examinations be submitted to the school no later than
th
October 15
of the year the child is first enrolled or as required by the school for other children. The examination must be completed within one year prior to the child
beginning school.
Student Name: ___________________________________________ Birth Date: _____________ Sex: _____Grade: _____
(Last)
(First)
(Middle Initial)
(Mo.) (Day)
(Yr.)
Parent or Guardian: ____________________________________________________ Phone: ________________________
(Last)
(First)
(Area Code)
Address: ______________________________________________________________ County: _______________________
(Number)
(Street)
(City)
(Zip Code)
To Be Completed By Examining Doctor
Case History
Date of Exam: ________________
Ocular History:
Normal
or Positive for: _______________________________________________________
Medical History:
Normal
or Positive for: _______________________________________________________
Drug Allergies:
NKDA
or Allergic to: ________________________________________________________
Other Information: ____________________________________________________________________________________
Examination
Refraction:
Distance
Near
Right
Left
Both
Both
Unaided Visual Acuity:
20 /
20 /
20 /
20 /
Best Corrected Visual Acuity:
20 /
20 /
20 /
20 /
Was refraction performed with cycloplegic agents?
Yes
No
Normal
Abnormal Not Able to Assess
Comments
External Exam (eye and adnexa)
_________________________
Internal Exam (media, lens, fundus, etc.)
_________________________
Neurological Integrity (pupils)
_________________________
Binocular Function (stereopsis)
_________________________
Accommodation and Vergence
_________________________
Color Vision
_________________________
IOP (glaucoma)
_________________________
Oculomotor Assessment
_________________________
Other: _______________________________
_________________________
Diagnosis
Normal
Myopia
Hyperopia
Astigmatism
Strabismus
Amblyopia
Other: ______________________________________________________________________________________________
Recommendations
1. Corrective Lenses:
No
Yes, glasses should be worn for:
Constant Wear
Near Vision
Far Vision
May Be Removed for Physical Education
2. Preferential seating recommended:
No
Yes Comments: _______________________________________
3. Recommend re-examination:
3 months
6 months
12 months
Other _______________
4. __________________________________________________________________________________________________
5 . __________________________________________________________________________________________________
Consent of Parent or Guardian
I agree to release the above information on my child or ward
Print Name: ___________________________________________
to appropriate school or health authorities.
Optometrist or Physician Who Provides Eye Examinations
Address: ____________________________________________
(Parent or Guardian’s Signature)
____________________________________________
Signature: ____________________________________________
Phone: ________________________________
Optometrist or Physician Who Provides Eye Examinations
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Parent category: Medical