EYE EXAMINATION SUMMARY
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1 Vision Services 1000 Schoolhouse Lane Greeley, CO Phone: (987) Fax: (987) EYE EXAMINATION SUMMARY Patient s Name Jason Date January 15, 2010 Date of Birth May 12, 2003 Social Security # Address 1777 Merry Circle City Greeley State Colorado Zip Dear Eye Care Specialist, The information you provide on this form will be used to determine this child s visual needs in an academic setting. (S)he may be eligible to receive special services, which may include special instruction, academic support, and/or the use of special materials and equipment. Your thoroughness and timeliness in completing this report is greatly appreciated. Date Needed March 1, 2010 Permission to Release Records I certify that I am the parent or legal guardian of the child who is the subject of this eye examination. I give my permission for Cherry Creek Schools to receive this information. Signature Charlie Date Doctor s Name Eileen Smith Doctor s Address 9999 Kennedy Drive Metropolis, CO Phone (303) Fax (303) Date of most recent eye examination March 2009 Projected date for re-evaluation/follow-up Spring 2011 Diagnosis: (primary cause of visual loss) Retinopathy of Prematurity Ocular History: (describe etiology, previous eye diseases, injuries, or operations)
2 Eye Condition ROP Age of Onset: Birth. History Premature birth at 26 weeks gestation, maternal narcotics use, additional developmental disabilities suspected autism Prognosis (check all that apply) Permanent Stable Improving Communicable Recurring Progressive Can Be Improved Visual Acuity If the acuity can be measured, complete this table using Snellen equivalents or NLP,LP, HM, CF Distance Acuity Near Acuity Without With Best Without With Best Correction Correction Correction Correction Right Eye Left Eye Both Eyes Refraction: Right Eye Left Eye Visual Fields There is no apparent visual field restriction. There is a field restriction. Describe The visual fields are restricted to 20 degrees or less. If you are unable to measure acuity, please check the most appropriate estimation Legally Blind (20/200 or less) Restricted Visual Fields (20 degrees or less) Low Vision (20/70 or less) Normal to Slightly Reduced Visual Fields Normal Acuity Cortical Visual Impairment Examination: (describe any abnormal function)
3 Muscle Function Intraocular Pressure Binocular Vision Color Vision Photophobia Contrast Sensitivity Ophthalmoscopy Normal Abnormal Describe Recommended Treatment: (e.g. glasses, low vision evaluation, medication, patches, surgery, referral to specialists, genetic analysis, etc.) Patient untestable due to inability to communicate and behavioral outbursts Precautions or Physical Restrictions: No Contact Sports Additional Suggestions & Comments: (lighting preferences, optimal viewing, etc.) Return to: Jane Doe John Doe TVI Joe Somebody Vision Services 1000 Schoolhouse Lane Somewhere, CO Fax: (987) Dr. Eileen Smith (303) Name of Licensed Ophthalmologist or Optometrist Phone # Dr. Eileen Smith Signature of Licensed Ophthalmologist or Optometrist Date
4 Assessment of Residual Vision in Multiply Impaired Children Name Jason Evaluator TVI Date of Birth May 12, 2003 Grade Kindergarten Item Pupillary Response Muscle Imbalance Blink Reflex Different Visual Behaviors Eye Preference Central Fields Peripheral Fields Visual Field Preference Date Present (P) Absent (A) O.D., O.S., O.U. Distance of light/object Type & size of light/object Illumination 2-17 P OU 6 in. Penlight Dark 2-17 A OU 3 in. Penlight Dark 2-17 A Hand Normal 2-17 P 1 in. Red flashing Dim to lights & 6 ft. Sunlight Normal 2-17 P OD 1 in. Flashlight Dark 2-17 P OU 6 in. Flashlight Dark 2-17 P OU 6 in. Flashlight Dark 2-17 N/O Comments Attend to flashing lights upon request for secs. Walk towards windows on sunny days
5 Tracking 2-17 P OU 3 in. Penlight Dark Jerky tracking for only 1-2 secs Shifting Attention 2-17 P OU 3 in. Flashing red lights Normal Scanning 2-17 P OU 3 in. Penlight Dark Reaching 2-17 A Additional Information Jason does not appear to use his central vision to see detail Jason does not maintain steady fixation. Jason was unable to follow the penlight, and his eye movements appeared to be jerky during tracking. Jason will stare at colored lights on a Light Brite at a distance of 1 inch in a dimly lit environment. Jason does not appear to use his residual vision as a means for gathering information about his environment. Jason does use light perception and peripheral vision when traveling. On sunny days, he is able to locate windows/doors. He can also visually detect the presence of a wall while trailing Jason engages in eye poking frequently
6 Teller Acuity Cards Score Sheet Child s Name: Jason ID #: Date: Evaluator: TVI Site: School OU OD OS (Circle One) Test Distance: 38 cm 55cm 84 cm.23 cy/cm cy/cm cy/cm cy/cm cy/cm cy/cm 1.6 cy/cm 2.4 cy/cm 3.2 cy/cm 4.8 cy/cm 6.5 cy/cm 9.8 cy/cm 13.0 cy/cm 19.0 cy/cm 26.0 cy/cm 38.0 cy/cm Blank Acuity: 20/710
7 Teller Card Acuities CY/CM 38 CM 55 CM 84 CM / / / / / / / /960 20/ / /710 20/ /670 20/470 20/ /540 20/380 20/ /360 20/260 20/ /270 20/ /180 20/130 20/ /130 20/94 20/ /89 20/63 20/ /66 20/47 20/ /45 20/32 20/ /33 20/24 20/ /23 20/16 20/11
8 MOTIVATION ASSESSMENT SCALE Name Jason Rater TVI Date Behavior Description Eye-Poking Setting Description Across all settings Instructions: The Motivation Assessment Scale is a questionnaire designed to identify those situations in which an individual is likely to behave in certain ways. From this, informed decisions can be made concerning the selection of appropriate reinforcers and treatments. To complete the Motivation Assessment Scale, select one behavior that is of particular interest. It is important that you identify the behavior very specifically. Aggressive, for example is not as good a description as hits his sister. Once you have specified the behavior to be rated, read each question carefully and circle the one number that best describes your observations of this behavior. Never Almost Never Seldom Half the Time Usually Almost Always Always 1. Would the behavior occur continuously, over and over, if this person was left alone for long periods of time? 2. Does the behavior occur following a request to perform a difficult task? 3. Does the behavior seem to occur in response to your talking to other persons in the room? 4. Does the behavior ever occur to get a toy, food, or activity that this person has been told that he or she can t have? 5. Would the behavior occur repeatedly in the same way, for very long periods of time, if no one was around? 6. Does the behavior occur when any request is made of this person? 7. Does the behavior occur whenever you stop attending to this person? 8. Does the behavior occur when you take away a favorite toy, food, or activity? 9. Does it appear to you that this person enjoys performing the behavior? 10. Does this person seem to do this behavior to upset or annoy you when you are trying to get him or her to do what you ask? 11. Does this person seem to do the behavior to upset or annoy you when you are not paying attention to him or her? 12. Does the behavior stop occurring shortly after you give the person the toy, food, or activity that he or she has requested? 13. When the behavior is occurring, does this person seem calm and unaware of anything else going on around him or her? 14. Does the behavior stop occurring shortly after you stop working or making demands of this person?
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