State of Illinois Examination Report

Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides 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 the first day of the school year the child enters the Illinois school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.

Student Name ______(Last) (First) (Middle Initial) Birth Date ______Gender ______Grade _____ (Month/Day/Year) Parent or Guardian ______(Last) (First) Phone ______(Area Code) Address ______(Number) (Street) (City) (ZIP Code) County ______

To Be Completed By Examining Doctor

Case History Date of exam ______Ocular history: K Normal or Positive for ______Medical history: K Normal or Positive for ______Drug : K NKDA or Allergic to ______Other information ______

Examination Distance Near Right Left Both Both Uncorrected 20/ 20/ 20/ 20/ Best corrected visual acuity 20/ 20/ 20/ 20/

Was performed with dilation? K Yes K No

Normal Abnormal Not Able to Assess Comments External exam (lids, lashes, , etc.) KK K______Internal exam (vitreous, lens, fundus, etc.) KK K______Pupillary reflex () KK K______Binocular function () KK K______Accommodation and KK K______Color vision KK K______Glaucoma evaluation KK K______Oculomotor assessment KK K______Other ______KK K______NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.

Diagnosis K Normal K K Hyperopia K K K Other ______

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Recommendations 1. Corrective lenses: K No K Yes, or contacts 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 12 months K Other ______

4. ______

5. ______

Print name______License Number______Optometrist or physician (such as an ophthalmologist) who provided the eye examination K MD K OD K DO Consent of Parent or Guardian I agree to release the above information on my child Address ______or ward to appropriate school or health authorities. ______(Parent or Guardian’s Signature)

Phone ______(Date)

Signature ______Date ______

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

Page 2 Printed by Authority of the State of Illinois IOCI1271-09 6/09