visual screening for infant and kids

HAND-OPERATED VISUAL SCREENING FOR INFANTS and CHILDREN:

Patient's Name:
Address:
Age:
Hs:
Ps:

1) VISUAL SCREENING TESTS FOR AN INFANT:

Response to light(penlight)
(Light reflex @ Near):
Result:B__NR___

Pupil response
(penlight)
(Light reflex @ Near):
Result:C/D__NR__


Ability to follow a target :
(Look and follow an object or toy)
(Near)
Result:

Visually evoked response testing:
(Manual stimulation of the eyes with either a bright light or special pattern applied)
Tests/movts performed(@13in):
zigzags:
twirls:
up and down movt:

Result:

------------------------------------
2) VISUAL SCREENING FOR AN OLDER INFANT AND TODDLER:

Response to light(penlight)
(Light reflex @ Near):
Result:B__NR__

Pupil response
(penlight)
(Light reflex @ Near):
Result:C/D__NR__


Ability to follow a target :
(Look and follow an object or toy)
(Near)
Result:

Visually evoked response testing:
(Manual stimulation of the eyes with either a bright light or special pattern applied)
Tests performed:
Tests/movts performed(@13in):
zigzags:
twirls:
up and down:
Result:

Cover/uncover test
CO test result:
ACO test result:

------------------------------------------
3) VISUAL SCREENING FOR PRESCHOOLERS:

Response to light(penlight)
(Light reflex @ Near):
Result:B__NR __

Pupil response
(penlight)
(Light reflex @ Near):
Result:C/D__NR__


Ability to follow a target :
(Look and follow an object or toy)
(Near)
Result:

Visually evoked response testing:
(Manual stimulation of the eyes with either a bright light or special pattern applied)
Tests performed:
Tests/movts performed(@13in):
zigzags:
twirls:
up and down:

Result:


Cover/uncover test
CO test result:
ACO test result:

Visual acuity tests
Far OD
Far OS
Near OD
Near OS

Preschoolers:charts may consist of pictures or stories instead of letters of the alphabet.

Dalton test/color vision test:
Result:

------------------------------------------
4) VISUAL SCREENING FOR SCHOOL-AGED CHILDREN:

Response to light(penlight)
(Light reflex @ Near):
Result:B__NR__

Pupil response
(penlight)
(Light reflex @ Near):
Result:C/D__NR__


Ability to follow a target :
(Look and follow an object or toy)
(Near)
Result:

Visually evoked response testing:
(Manual stimulation of the eyes with either a bright light or special pattern applied)
Tests/movts performed(@13in):
zigzags:
twirls:
up and down:

Result:

Cover/uncover test
CO test result:
ACO test result:

Dalton Test:
Result:


Visual acuity tests
Far OD
Far OS
Near OD
Near OS

Formal vision tests(Refraction):
ODf:
ODn:
OSf:
OSn:

Old Rx:
OD:
OS:

New Rx:
OD:
OS:

-----------------------------------------
Further tests needed :
Eye patching:

Eye exercises:

Vision therapy:

Health and wellness services:

Herbology app:


Schedule:


Date visual training started:


Date visual training shall end:


Next follow up check up:


Notes: