State of Illinois

Eye Examination Report

Illinois law requires that proof of an eye examination by an optometrist or physician who provides complete eye examinations be
submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for other children.
The examination must be completed within one year prior to October 15 of the year the child enters an Illinois school.

Student Name ________________________________________________________________________________________________

(Last)

Birth Date ____________________ Sex _____ Grade _______

(First)

(Middle Initial)

(Month/Day/Year)

Parent or Guardian ____________________________________________________________________________________________

(Last)

(First)

Phone ______________________________
(Area Code)

Address _____________________________________________________________________________________________________
(Number)

(Street)

(City)

County ____________________________________________
Case History
Date of Exam ________________

Ocular History:

Medical History:
Drug Allergies:

To Be Completed By Examining Doctor

K Normal

or Positive for _______________________________

K NKDA

or Allergic to ________________________________

K Normal

(ZIP Code)

or Positive for _______________________________

Other Information _____________________________________________________________________________________________

Examination
Refraction:

Unaided Visual Acuity

Best Corrected Visual Acuity

Distance

Right
20/
20/

Left
20/
20/

Both
20/
20/

Was refraction performed with cycloplegic agents?

External Exam (eye and adnexa)
Internal Exam (media, lens, fundus, etc.)
Neurological Integrity (pupils)
Binocular Function (stereopsis)
Accommodation and Vergence
Color Vision
IOP (glaucoma)
Oculomotor Assessment
Other _________________________
Diagnosis
K Normal

K Myopia

K Hyperopia

K Yes

Near

Both
20/
20/

Normal
K
K
K
K
K
K
K
K
K

K Astigmatism

K No

Abnormal
K
K
K
K
K
K
K
K
K

K Strabismus

Not Able to Assess

K
K
K
K
K
K
K
K
K

Comments
__________
__________
__________
__________
__________
__________
__________
__________
__________

K Amblyopia

Other _______________________________________________________________________________________________________
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State of Illinois
Eye Examination Report
Recommendations
1. Corrective Lenses: K No K Yes, glasses should be worn for:
K Constant Wear K Near Vision K Far Vision
K May Be Removed for Physical Education

2. Preferential seating recommended:

K No

K Yes

Comments ________________________________________________________________________________________________

_________________________________________________________________________________________________________

3. Recommend re-examination:

K 3 months

K 6 months

K Other ____________________________________

K 12 months

4. _________________________________________________________________________________________________________
5. _________________________________________________________________________________________________________
Print name___________________________________________
Optometrist or Physician who provides eye examinations

Address ____________________________________________
Phone

Consent of Parent or Guardian

I agree to release the above information on my child

or ward to appropriate school or health authorities.
(Parent or Guardians Signature)

____________________________________________
____________________________________________

Signature ____________________________________________
Optometrist or Physician who provides eye examinations

(Date)
Date ___________________

(Source: Amended at 32 Ill. Reg. _________, effective ___________)

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Printed by Authority of the State of Illinois

5/08

IISG08-1048