Vision Exam Report qxd - Illinois Department of Public Health - idph state il 2025

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. 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.
4. 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.
5. For symptoms noted, check any observable signs that may require attention. This assists healthcare providers in understanding potential issues.
6. Complete the 'REASON FOR REFERRAL' section if necessary. Indicate if the child is wearing glasses or under care and provide relevant details.
7. The examining doctor will fill out their section regarding visual acuity and any recommended treatments. Ensure all fields are completed accurately.
8. Finally, obtain signatures from both the parent or guardian and doctor to validate the report before submission.

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