Clinical Low Vision Referral Form

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Kentucky School for the Blind
Clinical Low Vision Referral Form PLEASE PRINT
-
First Name: _______________ MI: ____ Last Name: _____________________
Date of Birth: _____________________________ Sex:
Male
Female
Street Address: ____________________ City: ________________ State: _____
Zip _________ District: _______________ Phone: _______________________
Parent / Guardian: ___________________________________________________
Parent / Guardian: ___________________________________________________
Cell Phone: _____________________ Work Phone: _______________________
Email: _____________________________________________________________
Grade: _______ School: ______________________________________________
School Address: _____________________________________________________
School Phone: _________________________ Fax: _________________________
How Served:
VI Only
Primary Reading Medium:
VI Multiple
504
Print
Auditory
Braille
Other
Pre-reader
Non-reader
VI Teacher: __________________________________________________________
Phone: ______________________ Email: _________________________________
DoSE: _______________________________________________________________
Phone: _______________________ Email: _________________________________
1|Page
Updated: May 2013
Kentucky School for the Blind
Clinical Low Vision Referral Form PLEASE PRINT
-
HISTORY:
Visual condition:
Primary: ____________________________________________________
Secondary: __________________________________________________
Date of Last Exam: __________________ with Dr. ___________________________________
Near
Distant
Without Correction
With Correction
With Low Vision Device
Without Correction
With Correction
With Low Vision Device
OD:
OD:
OD:
OD:
OD:
OD:
OS:
OS:
OS:
OS:
OS:
OS:
OU:
OU:
OU:
OU:
OU:
OU:
OD = Right Eye
Prescription lenses/contacts:
No
OS = Left Eye
Yes …
Near
OU = Both Eyes
Distant
Protection
Full-Time Wear
Has the student had a clinical low vision before?
No
Yes ... When? ________________
Has there been a recent change in vision?
No
Yes
If yes, please explain: ____________________________________________________________
Did or does the student use:
Magnifier
Monocular
Without low vision devices, does the student experience
difficulty using his or her vision to do any of the following
activities:
Reading regular print textbooks
Reading regular print handouts
Reading regular print dictionaries, phone books or maps
Reading labels in clothing
Copying from books
Using a computer
Reading street signs
Reading the board
Matching or identifying colors
Recognizing faces
Form completed by: ______________________________
Appointment Preference:
2|Page
Morning
CCTV
Other ______________
What is your specific concern
about the student’s vision loss?
_________________________
_________________________
_________________________
_________________________
_________________________
What are one or two activities
that you would like to visually
make better for the student?
_________________________
_________________________
_________________________
_________________________
_________________________
Date: __________________________
Afternoon
Updated: May 2013
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