Ill. Admin. Code tit. 77, § 665.APPENDIX 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.

Student Name:

(Last)

(First)

(Middle Initial)

Birth Date:

Gender:

Grade:

(Mo.)

(Day)

(Yr.)

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:	q Normal	or Positive for:
Medical History:	q Normal	or Positive for:
Drug Allergies:	q 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? q Yes q No

	Normal	Abnormal	Not Able to Assess	Comments
External Exam (lids, lashes, cornea, etc.)	q	q	q
Internal Exam (vitreous, lens, fundus, etc.)	q	q	q
Pupillary Reflex (pupils)	q	q	q
Binocular Function (stereopsis)	q	q	q
Accommodation and Vergence	q	q	q
Color Vision	q	q	q
Glaucoma Evaluation	q	q	q
Oculomotor Assessment	q	q	q
Other:_____________________________	q	q	q

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

q Normal	q Myopia	q Hyperopia	q Astigmatism
q Strabismus	q Amblyopia	Other: ___________________________________

Recommendations

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

Print Name:		Lic. No.:
	Optometrist or Physician (such as an ophthalmologist) Who Provided the Eye Examination
	qMD qOD qDO
Address:			Consent of Parent or Guardian I agree to release the above information on my child or ward to appropriate school or health authorities.

Phone:

Signature:			(Parent's or Guardian's Signature)
	Optometrist or Physician (such as an ophthalmologist) Who Provided the Eye Examination		Date
	qMD qOD qDO
Date:

(Source: Amended at 33 Ill. Reg. 8459, effective June 8, 2009)