TITLE 77: PUBLIC HEALTH
CHAPTER I: DEPARTMENT OF PUBLIC HEALTH
SUBCHAPTER i: MATERNAL AND CHILD HEALTH
PART 665 CHILD HEALTH EXAMINATION CODE
SECTION 665.APPENDIX A ILLINOIS DEPARTMENT OF PUBLIC HEALTH EYE EXAMINATION REPORT



Section 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)