Ill. Admin. Code tit. 77, pt. 665, subpt. F, app A - Illinois Department of Public Health Eye Examination Report

State of Illinois

Eye Examination Report

Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eye examinations be submitted to the school no later than 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 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.

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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: _____________________________________

Recommendations

1.	Corrective Lenses:	[] No	[] Yes, glasses or contacts should be worn for:
[] Constant Wear			[] Near Vision		[] Far Vision
[] May Be Removed for Physical Education/Recess
2.	Preferential Seating Recommended:	[] No	[] Yes	Comments:		___________________
3.	Recommend Re-examination:	[] 3 months		[] 6 months		[] 12 months
[] Other
4.	________________________________________________________________
5.	________________________________________________________________

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Notes

Ill. Admin. Code tit. 77, pt. 665, subpt. F, app A

Amended at 33 Ill. Reg. 8459, effective June 8, 2009