Form Idph V-4 - Vision Exam Report Form - Illinois Department Of Public Health
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1Illinois Department of Public Health
White
– Doctor’s Referral
VISION EXAMINATION REPORT
Canary – File
Date ____________________
Name ________________________________________________
Birth Date ________________________
Sex __________
Grade ____________
Parent or Guardian ________________________________________________________________________
Phone ____________________________
Address __________________________________________________________________________________
County ____________________________
Testing Location ______________________________
Testing Agency ____________________________________
Tester ______________________
TO BE COMPLETED FOLLOWING SCREENING
REASON FOR REFERRAL
TEST GIVEN
1.
Visual Acuity
1. Instrument Used ________________________________________
2.
Plus Sphere
a.
Visual Acuity
3.
Muscle Balance – Phoria
b.
Plus Sphere
4.
Near and Far Binocular Vision – Fusion
c.
Muscle Balance
SYMPTOMS NOTED
d.
Near and Far Binocular Vision
1.
Academic Achievement
e.
Other: ________________________________________
2.
Observable Signs: ____________________________________
TO THE DOCTOR
CHILD WEARING GLASSES OR UNDER CARE
Children wearing glasses or under care are not screened as part of the routine vision screening program. Observations by
screening technicians possibly indicate the following:
Frames broken / too small
Two years since last examination
Lenses scratched / broken
Other: ____________________________
TO BE COMPLETED BY EXAMINING DOCTOR
DISTANCE
PLEASE CHECK IF APPROPRIATE:
UNCORRECTED
BEST CORRECTED
Treatment recommended
(1)
(2)
VISUAL ACUITY
VISUAL ACUITY
Medical
RIGHT
LEFT
RIGHT
LEFT
Glasses
Contact Lenses
Other: __________________________________
Corrective lens prescribed
(3) Ocularmotor Assessment ________________________________________
Constant Wear
______________________________________________________________
Near Vision only
Far Vision only
______________________________________________________________
May be removed for physical education
(4) Diagnosis ______________________________________________________
______________________________________________________________
Visual field restriction
______________________________________________________________
Amblyopia exists
______________________________________________________________
(5) Comments ____________________________________________________
Muscle imbalance exists
Close work may be difficult or cause fatigue
______________________________________________________________
______________________________________________________________
Preferential seating needed
______________________________________________________________
Re-examination advised
Six months
IMPORTANT NOTICE
Twelve months
THIS STATE AGENCY IS REQUESTING DISCLOSURE OF INFORMATION THAT
Other: __________________________________
IS NECESSARY TO ACCOMPLISH THE STATUTORY PURPOSE AS OUTLINED
UNDER PUBLIC ACT 81-174. DISCLOSURE OF THIS INFORMATION IS VOLUN-
TARY, AND THERE IS NO PENALTY FOR NON-COMPLIANCE. THIS FORM HAS
Please print or stamp
BEEN APPROVED BY THE FORMS MANAGEMENT CENTER.
Doctors Name __________________________________________________
CONSENT OF PARENT OR GUARDIAN
Address ________________________________________________________
I agree to release the above information on my child or
City __________________________________________________________
ward to appropriate school or health authorities.
Date of Examination ______________________________________________
PARENT OR GUARDIAN’S SIGNATURE
______________________________________________________________
IDPH V-4
IL 482-0847
Revised 8-99
DOCTOR’S SIGNATURE
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