Board Of Education And Services For The Blind

Board of Education and Services for the Blind

184 Windsor Avenue

Windsor , CT 06095

4830-V LOW VISION EVALUATION REPORT

Client Name: _______________________________________________

Client ID #: _______________________________________________

Doctor’s Name: ___________________________________________

Ref erred by: _______________________________________________

DATE OF EVALUATION: ______________________________________

Primary Visual Diagnosis:

Right Eye:__________________________________________________

Left Eye: ___________________________________________________

Both Eyes: _________________________________________________

Additional Visual Diagnoses:

Right Eye:__________________________________________________

Left Eye: ___________________________________________________

Both Eyes: _________________________________________________

Other Medical Concerns: _____________________________________

Visual Prognosis-

Stable: _______

Progressive: _______

Improving: _______

Additional Comments:___________________________________

Best Distance Acuity-

Right Eye: _______

Left Eye: _______

Both Eyes: _______

Place an X in front of all statements that apply:

_____ Glasses or contact lenses needed to achieve this acuity

_____ With Eccentric Viewing:

Visual Fields: Put an X in front of all that apply.

Right Eye:

______Full

______Central Scotoma

______Constriction

Other: ________________________

Left Eye:

______Full

______Central Scotoma

______Constriction

Other: ________________________

Place an X in front of all statements that apply:

_____ Individual is legally blind based on a visual field of 20 degrees or less in both eyes.

_____ Individual is legally blind based on acuity of 20/200 or worse with best correction in the better eye.

_____ Individual is visually impaired (A person has impaired vision if his or her central visual acuity is equal to or worse than 20/70, but better than 20/200, in the better eye with correcting lenses.)

Place an X in front of all that apply and explain:

_____ Nystagmus: _________________________________________

_____ Null Point: _________________________________________

_____ Head / Body Posture: _________________________________

_____ Monocular: ________________________________________

_____ Binocular

_____ Dominant Eye: _______

_____ Color Vision Impairment: _________________________

_____ Contrast Sensitivity Reduction: _________________________

_____ Depth Perception Reduction: ___________________________

_____ Best Location to Present Materials: ______________________

Note: BESB provides the most effective, least expensive magnification/optical device(s) that enable eligible consumers to perform necessary visual tasks.

Glasses Recommended- Complete all that apply.

Distance Prescription:

RX#1 Right Eye: ____________________________________________

RX#1 Left Eye: _____________________________________________

Tasks/Goal: ______________________________________________

Near Prescription:

RX#2 Right Eye: ____________________________________________

RX#2 Left Eye: _____________________________________________

Tasks/Goal: ______________________________________________

Functional Print Size and Viewing Distance: ____________________

Additional Prescription:______________________________________

RX#3 Right Eye: ____________________________________________

RX#3 Left Eye: _____________________________________________

Tasks/Goal: ______________________________________________

Optical Devices Recommended (with optimal print size and viewing distance)

1. ________________________________________________________