Eye Examination Form For School Entry
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1KDE/DSS
Kentucky Eye Examination Form for School Entry
KDESHS004
KRS 156.160 (1) (g) requires proof of a vision examination by an optometrist or ophthalmologist. This evidence shall be submitted to the school no later
than January 1 of the first year that a three (3), four (4), five (5) or six (6) year old child is enrolled in public school, public preschool, or Head Start
program.
PLEASE COMPLETE THE IDENTIFYING INFORMATION
Date of student’s enrollment: _____________________
Date of Vision Examination: ______________________
IDENTIFYING INFORMATION
Student Name: ____________________________________________________________________________________________________________________
Date of Birth: _____________________________________________________________________________________________________________________
Parent or Guardian Name: ___________________________________________________________________________________________________________
CASE HISTORY
Date of Exam: ___________________________________________________________________________________________________________________
Ocular History:
Normal or Positive for: ________________________________________________________________________________________
Medical History:
Normal or Positive for: ________________________________________________________________________________________
Drug Allergies:
NKDA or Allergic to: ________________________________________________________________________________________
ڤ
ڤ
ڤ
ڤ
Family Ocular and Medical History:
Amblyopia
Strabismus
Glaucoma
Diabetes
Other: ___________________________________________________________________ ________________________________________________________
Other Pertinent Information: _________________________________________________________________________________________________________
ڤ
ڤ
Refraction with cycloplegic? (Please indicate one.)
YES
NO
OD
OS
Unaided Acuity
20/
20/
Best Corrected Acuity
20/
20/
Type of Examination
Normal
Abnormal
Notable to Assess
External Exam (eye and adnexa)
Internal Exam (media, lens, fundus, etc)
Neurological Integrity (pupils)
Binocular Function (stereopsis)
Accommodation and convergence
Color Vision
Diagnosis:
ڤ
ڤ
ڤ
ڤ
ڤ
ڤ
Normal
Myopia
Hyperopia
Astigmatism
Strabismus
Amblyopia
Other: __________________________________________________________________________________________________________
Recommendations:
ڤ
ڤ
1 Glasses prescribed:
YES
NO
2 _________________________________________________________________________________________________________
3 _________________________________________________________________________________________________________
Age appropriate and suggested anticipatory guidance (health assessments):
ڤ
Educate (parents/patients) about eye/vision disorders and needed vision care
ڤ
Counsel (parents/patients) regarding eye safety
ڤ
Stress importance of early, preventative eye care
ڤ
Recommend re-examination, as appropriate
Signed: _______________________________________________________________
Date: ___________________________________
Optometrist/Ophthalmologist
Address: _______________________________________________________________________
Telephone: (
) ______________________________
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