VISION SCREENING FORM VISION SCREENING FORM

Name of School: _____________________________ Date: _________ Name of School: _____________________________ Date: _________
Address of School: _________________________ District: _________ Address of School: _________________________ District: _________
Name of Child: ____________________________ Age: ____ Sex: ___ Name of Child: ____________________________ Age: ____ Sex: ___
Grade & Section: __________________________________________ Grade & Section: __________________________________________
Home Address: ____________________________________________ Home Address: ____________________________________________
Occupation of Father: ______________________________________ Occupation of Father: ______________________________________
Occupation of Mother: ______________________________________ Occupation of Mother: ______________________________________
Special Health Problem: _____________________________________ Special Health Problem: _____________________________________
Student’s Complaint Related to Eye and Vision: __________________ Student’s Complaint Related to Eye and Vision: __________________
_________________________________________________________ _________________________________________________________
Interview Interview
Child Family Child Family
Blindness Blindness
Poor Vision Poor Vision
Abnormal Eye Position Abnormal Eye Position
Screener’s Observation Screener’s Observation
General (Please Check) General (Please Check)
Squinting of Eye to See Difficulty Seeing at Far Squinting of Eye to See Difficulty Seeing at Far
Abnormal Head Posture Difficulty Seeing at Near Abnormal Head Posture Difficulty Seeing at Near
Abnormal Eye Awkwardness in Walking related Abnormal Eye Awkwardness in Walking related
Appearance to Sight Appearance to Sight
Eyes not Aligned Learning/ Reading Difficulty Eyes not Aligned Learning/ Reading Difficulty
Eyes Eyes
Eyelids Size of the Eye Eyelids Size of the Eye
White Part of the Eye Shape of the Eye White Part of the Eye Shape of the Eye
(Sclera/Conjunctiva) (Sclera/Conjunctiva)
Black/Brown Part of the Eye (Iris/Pupil) Surrounding Area Black/Brown Part of the Eye (Iris/Pupil) Surrounding Area
Light Reflex Test: Normal Abnormal Light Reflex Test: Normal Abnormal
Visual Acuity Visual Acuity
Far Near Far Near

Right Eye Right Eye

Left Eye Left Eye

FOR REFERRAL FOR REFERRAL

Name and Signature of Vision Screener Name and Signature of Vision Screener

Eye Movement Test: Normal Abnormal Eye Movement Test: Normal Abnormal

UVA Far Near Aided Far Near UVA Far Near Aided Far Near

OD OD OD OD

OS OS OS OS

Refraction: Refraction:
Far Near Far Near

OD OD

OS OS