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Vision Exam Report qxd - Illinois Department of Public Health - idph state il 2026
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- Click ‘Get Form’ to open it in the editor.
- Begin by entering the date at the top of the form, followed by the child's name and birth date. Ensure accuracy as this information is crucial for identification.
- Fill in the personal details including sex, grade, phone number, address, county, testing location, and agency. This section helps in tracking and managing records effectively.
- In the 'TO BE COMPLETED FOLLOWING SCREENING' section, indicate the instrument used for testing and check all applicable tests given such as Visual Acuity or Muscle Balance.
- For symptoms noted, check any observable signs that may require attention. This assists healthcare providers in understanding potential issues.
- Complete the 'REASON FOR REFERRAL' section if necessary. Indicate if the child is wearing glasses or under care and provide relevant details.
- The examining doctor will fill out their section regarding visual acuity and any recommended treatments. Ensure all fields are completed accurately.
- Finally, obtain signatures from both the parent or guardian and doctor to validate the report before submission.
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Related links
The examination must be completed within one year prior to the child beginning school. Student Name: Birth Date: Sex: Grade: . (Last). (First).Read more
Illinois law requires that proof of an eye examination by an optometrist or physician. The examination must be completed within one year