<p> Kentucky School for the Blind</p><p>Clinical Low Vision Referral Form - PLEASE PRINT</p><p>First Name: ______MI: ____ Last Name: ______</p><p>Date of Birth: ______Sex: Male Female</p><p>Street Address: ______City: ______State: _____</p><p>Zip ______District: ______Phone: ______</p><p>Parent / Guardian: ______</p><p>Parent / Guardian: ______</p><p>Cell Phone: ______Work Phone: ______</p><p>Email: ______</p><p>Grade: ______School: ______</p><p>School Address: ______</p><p>School Phone: ______Fax: ______</p><p>How Served: VI Only VI Multiple 504 Other</p><p>Primary Reading Medium: Print Braille Auditory Pre-reader Non-reader</p><p>VI Teacher: ______</p><p>Phone: ______Email: ______</p><p>DoSE: ______</p><p>Phone: ______Email: ______</p><p>1 | P a g e U p d a t e d : M a y 2 0 1 3 Kentucky School for the Blind</p><p>Clinical Low Vision Referral Form - PLEASE PRINT</p><p>HISTORY: </p><p>Visual condition: Primary: ______</p><p>Secondary: ______</p><p>Date of Last Exam: ______with Dr. ______</p><p>Near Distant</p><p>Without With With Low Vision With Without Correction With Low Vision Device Correction Correction Device Correction</p><p>OD: OD: OD: OD: OD: OD: </p><p>OS: OS: OS: OS: OS: OS: </p><p>OU: OU: OU: OU: OU: OU: </p><p>OD = Right Eye OS = Left Eye OU = Both Eyes</p><p>Prescription lenses/contacts: No Yes … Near Distant Protection Full-Time Wear</p><p>Has the student had a clinical low vision before? No Yes ... When? ______</p><p>Has there been a recent change in vision? No Yes</p><p>If yes, please explain: ______Did or does the student use: Magnifier Monocular CCTV Other ______</p><p>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 ______</p><p>2 | P a g e U p d a t e d : M a y 2 0 1 3 Kentucky School for the Blind</p><p>Clinical Low Vision Referral Form - PLEASE PRINT Matching or identifying colors ______Recognizing faces ______</p><p>Form completed by: ______Date: ______</p><p>Appointment Preference: Morning Afternoon</p><p>3 | P a g e U p d a t e d : M a y 2 0 1 3</p>