Title: Vision: Eye Examination Report

State of Illinois Eye Examination Report

State of Illinois
Illinois Department of Public Health

Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who pro- vides eye examinations be submitted to the school no later than October 15 of the year the child is first enrolled or as re- quired by the school for other children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinois school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.

Student Name 	
(Last)	(First)	(Middle Initial)

Birth Date 	
(Month/Day/Year)

Gender 	

Grade 	

Parent or Guardian 	
(Last)	(First)
Phone	
(Area Code)
Address 	
(Number)	(Street)	(City)	(ZIP Code)
County 	

	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

| Distance | Near
| Right | Left | Both | Both
Uncorrected visual acuity | 20/ | 20/ | 20/ | 20/
Best corrected visual acuity | 20/ | 20/ | 20/ | 20/

Was refraction performed with dilation? □ Yes □ No

| Normal | Abnormal | Not Able to Assess | Comments
External exam (lids, lashes, cornea, etc.) | □ | □ | □ |
Internal exam (vitreous, lens, fundus, etc.) | □ | □ | □ |
Pupillary reflex (pupils) | □ | □ | □ |
Binocular function (stereopsis) | □ | □ | □ |
Accommodation and vergence | □ | □ | □ |
Color vision | □ | □ | □ |
Glaucoma evaluation | □ | □ | □ |
Oculomotor assessment | □ | □ | □ |
Other | □ | □ | □ |
NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.

Diagnosis
□ Normal	□ Myopia	□ Hyperopia	□ Astigmatism	□ Strabismus	□ Amblyopia
Other 	

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Recommendations
Corrective lenses:	□ No	□ Yes, glasses or contacts should be worn for:
□ Constant wear	□ Near vision	□ Far vision
□ May be removed for physical education

Preferential seating recommended:	□ No	□ Yes
Comments 	

Recommend re-examination:	□ 3 months	□ 6 months	□ 12 months
□ Other 	

     	

Print name 	

Consent of Parent or Guardian
I agree to release the above information on my child or ward to appropriate school or health authorities.
(Parent or Guardian’s Signature) (Date)

Optometrist or physician (such as an ophthalmologist) who provided the eye examination □ MD □ OD □ DO

Address		

License Number	

Phone		

Signature 		Date 	

(Source: Amended at 32 Ill. Reg. 	, effective 	)

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Printed by Authority of the State of Illinois	IOCI 15-391