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Get and Sign Eye Examination Form

Get and Sign Eye Examination Form

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Binocular Function stereopsis Accommodation and Vergence Color Vision IOP glaucoma Oculomotor Assessment Other Near Both No Abnormal Not Able to Assess Comments Diagnosis Myopia Hyperopia Astigmatism Strabismus Amblyopia Recommendations 1. Corrective Lenses Yes glasses should be worn for 2. Preferential seating recommended 3. Recommend re-examination 3 months Constant Wear Near Vision May Be Removed for Physical Education Yes Comments 12 months Print Name Consent of Parent or Guardian I agree...
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