2080 Citygate Drive• Columbus, OH 43219

p: 614.445.3750 │ f: 614.445.3767

Part III. Vision Testing Results

Student:
Date of Birth:
School:
Date of Exam:
Evaluator:

Parent Comments/ Concerns:

Teacher Comments/Concerns:

Student Comments/Concerns:

A. Orientation and Mobility
1. Indoors, Skill Checklist
Identifies people by name/gender? / Yes / No
Avoids objects above and below waist? / Yes / No
Locates dropped objects? / Yes / No
Locates and accesses locker? / Yes / No
Locates rooms by numbers or names? / Yes / No
Travels independently on stairs? / Yes / No
Travels independently in school? / Yes / No
2. Outdoors, Skills Checklist
Identifies cars, trees, dumpsters? / Yes / No
Identifies fence, shrubs, light poles? / Yes / No
Detects surface, elevation changes? / Yes / No
Follows a sidewalk? / Yes / No
Travels independently around school? / Yes / No
B. Reading Media
1. Primary Reading media (mark only one)
Visual Reader / Braille Reader
Auditory Reader / Nonreader
Prereader
2. Additional Reading Media (mark all that apply)
Visual Reader / Braille Reader
Auditory Reader / Nonreader
Prereader
3. Describe use/type of optical devices, if any:
C. Visual Functions
1. Appearance of Eyes
a. Eyes Appear: / Normal / Abnormal
b. Check abnormalities observed.
Eye size / Pupil shape/size
Monocular / Eye contact
Nystagmus / Excessive binking
Strabismus / Cloudy cornea
Eyelids / Iris shape/color
Prosthesis / Discharge/watery eyes
Redness / Crust
Cataracts / Eccentric fixation
2. Describe
D.Muscle Balance and Eye Responses
1. Pupillary response to penlight at 12-14 inches:
Normal / Sluggish / None
2. Pupillary reflection using penlight at 30 inches:
Normal / Sluggish / None
3. Eye Alignment test (Strabismus):
Esotropia / Exotropia
Hypertropia / Hypotropia
4. Near point convergence up to 2 inches (normal) using finger puppet/pencil:
Yes / No
5. Ocular pursuit using finger puppet/pencil at 14 inches as indicated:
Pursuit is:
Smooth / Jerky
Crosses middle?
Yes / No
Moves
Head / Eyes / Both
6. Eye dominance (looks through tube):
Right / Left
None / Unable to determine
E. Peripheral Field (with wand)
Left/Right Vision:
Normal / Abnormal
(Normal = 180 degrees total, 150 for each eye)
Upper/Lower Vision:
Normal / Abnormal
(Normal = 120 total, upper = 50, lower = 70)
F. Color Discrimination
1. Matches colored markers, crayons, and pencils to colored lines drawn on paper:
Red / Orange
Blue / Purple
Yellow / Black
Green / Brown
2. Ranks/matches light, medium, dark shades (paint card samples):
Yes / No
G. Light Sensitivity and Preference:
1. Sees best in?
Dim / Medium / Bright
2. Prefers reading lamp?
Yes / No
3. Adjusts to outside?
Easily / Some difficulty / Great difficulty
4. Sensitive to bright light and glare?
Mildly / Moderately / Greatly
5. Difficulties seeing at night?
Yes / Some / No
H. Near Acuity and Discrimination
1. Central near acuity using chart at
Inches / OU
With correction:
Left / Right
Without correction:
Left / Right
2. Most comfortable print size:
pt. / Distance from paper to eyes: / in.
Smallest print size read:
pt.
Write each item that student cannot see/identify:
Coins/Bills?
Types of pictures?
Types of print materials?
I. Depth Perception:
1. Pours from one container to another?
Yes / No
2. Picks up beads from table and places in bottle?
Yes / No
3. Can string beads?
Yes / No
4. Catches a tennis ball rolled from / feet away.
J. Distance Acuity
1. / OU
With correction:
Left / Right
Without correction:
Left / Right
2. Locates wall clock at / feet.
3. Reads from board at / feet.
4. Imitates body movements? / feet.
5. Identifies common objects at / feet.
K. Handwriting
1. Is student's handwriting legible?
Yes / No
2. Can student read his/her own handwriting?
Yes / No
3. Can student write in cursive?
Yes / No
Attach handwriting sample.
L. Contrast Sensitivity Test
1. Can student distinguish between low contrast symbols?
Yes / No
2. Describe problem areas: