Clinical Low Vision Referral Form - PLEASE PRINT

Kentucky School for the Blind

First Name: ______MI: ____ Last Name: ______

Date of Birth: ______Sex: Male Female

Street Address: ______City: ______State: _____

Zip ______District: ______Phone: ______

Parent / Guardian: ______

Cell Phone: ______Work Phone: ______

Email: ______

Grade: ______School: ______

School Address: ______

School Phone: ______Fax: ______

How Served: VI Only VI Multiple 504 Other

Primary Reading Medium: Print Braille Auditory Pre-reader Non-reader

VI Teacher: ______

Phone: ______Email: ______

DoSE: ______

Phone: ______Email: ______

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Clinical Low Vision Referral Form - PLEASE PRINT

HISTORY:

Visual condition: Primary: ______

Secondary: ______

Date of Last Exam: ______with Dr. ______

Near Distant

Without With With Low Vision With Without Correction With Low Vision Device Correction Correction Device Correction

OD: OD: OD: OD: OD: OD:

OS: OS: OS: OS: OS: OS:

OU: OU: OU: OU: OU: OU:

OD = Right Eye OS = Left Eye OU = Both Eyes

Prescription lenses/contacts: No Yes … Near Distant Protection Full-Time Wear

Has the student had a clinical low vision before? No Yes ... When? ______

Has there been a recent change in vision? No Yes

If yes, please explain: ______Did or does the student use: Magnifier Monocular CCTV Other ______

Without low vision devices, does the student experience What is your specific concern difficulty using his or her vision to do any of the following about the student’s vision loss? activities: ______Reading regular print textbooks ______Reading regular print handouts ______Reading regular print dictionaries, phone books or maps ______Reading labels in clothing Copying from books What are one or two activities Using a computer that you would like to visually Reading street signs make better for the student? Reading the board ______

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Clinical Low Vision Referral Form - PLEASE PRINT Matching or identifying colors ______Recognizing faces ______

Form completed by: ______Date: ______

Appointment Preference: Morning Afternoon

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