VR2006E Interagency Eye Examination Report
Texas Workforce CommissionVocational Rehabilitation ServicesInteragency Eye Examination Report FORMTEXT ?Patient Information FORMTEXT ? Patient's name: FORMTEXT ?????Date of birth: FORMTEXT ?????Address: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Parent’s or spouse’s name: FORMTEXT ?????Home phone:( FORMTEXT ???) FORMTEXT ?????Cell phone (optional):( FORMTEXT ???) FORMTEXT ?????Email address: FORMTEXT ?????Attention eye care specialist: Address each item below. FORMTEXT ? Your thoroughness in completing this report is essential to this patient receiving appropriate services.Ocular History FORMTEXT ? Age at onset: FORMTEXT ?????Describe the ocular history, including eye diseases, injuries, or operations. FORMTEXT ?????Visual Acuity FORMTEXT ?If the acuity can be measured, complete the section below using Snellen acuities or Snellen equivalents, or NLP, LP, HM, or the distance at which the patient sees the 20/200 letter. FORMTEXT ?Without correction:Near right: FORMTEXT ?????Near left: FORMTEXT ?????Distance right: FORMTEXT ?????Distance left: FORMTEXT ?????With best correction:Near right: FORMTEXT ?????Near left: FORMTEXT ?????Distance right: FORMTEXT ?????Distance left: FORMTEXT ?????If the acuity cannot be measured, indicate below the most appropriate estimation. FORMTEXT ? FORMCHECKBOX Legally blind 20/200 or worse FORMCHECKBOX Legally blind due to visual field of 20 degrees or less in both eyes FORMCHECKBOX Between 20/70 and 20/199 FORMCHECKBOX Better than 20/70 FORMCHECKBOX Functions at the definition of blindness(for example, CVI)Muscle Function and Intraocular Pressure FORMTEXT ? Muscle function: FORMCHECKBOX Normal FORMCHECKBOX AbnormalDescribe: FORMTEXT ?????Intraocular pressure reading: Right: FORMTEXT ?????Left: FORMTEXT ?????Visual Field Test FORMTEXT ? Type of field test: FORMTEXT ?????(Confrontation is not acceptable. Attach a copy of the test.) FORMCHECKBOX No apparent visual field restriction exists. FORMCHECKBOX A visual field restriction existsDescribe the restriction: FORMTEXT ?????The visual field is restricted to: FORMTEXT ? FORMCHECKBOX 21 degrees to 30 degrees FORMCHECKBOX OD (right eye) FORMCHECKBOX OS (left eye) FORMCHECKBOX OU (both eyes) FORMCHECKBOX 20 degrees or less FORMCHECKBOX OD (right eye) FORMCHECKBOX OS (left eye) FORMCHECKBOX OU (both eyes)Color Vision and Photophobia FORMTEXT ? FORMCHECKBOX Normal FORMCHECKBOX Abnormal Photophobia: FORMCHECKBOX Yes FORMCHECKBOX NoType of test. Attach a copy of the test. FORMTEXT ?????Diagnosis FORMTEXT ? Diagnosis (primary cause of visual loss): FORMTEXT ?????ICD 10 code: FORMTEXT ?????_____________ICD 10 code: FORMTEXT ?????_____________Summarize the diagnosis. FORMTEXT ?????Prognosis FORMTEXT ? FORMCHECKBOX Permanent FORMCHECKBOX Recurrent FORMCHECKBOX Improving FORMCHECKBOX Progressive FORMCHECKBOX Stable FORMCHECKBOX Can be improved FORMCHECKBOX Unable to determine prognosis at this time. FORMCHECKBOX At risk for vision loss; this customer is under the age of 3 and/or the degree of vision loss cannot be determined.Treatment Recommended FORMTEXT ? Select all that apply. FORMTEXT ? FORMCHECKBOX GlassesPrescription: Right: FORMTEXT ????? Left: FORMTEXT ????? FORMCHECKBOX ContactsPrescription: Right: FORMTEXT ????? Left: FORMTEXT ????? FORMCHECKBOX PatchesRight: FORMTEXT ????? Left: FORMTEXT ????? FORMCHECKBOX Clinical low vision evaluation to determine: FORMTEXT ????? FORMCHECKBOX Medication: FORMTEXT ????? FORMCHECKBOX Surgery FORMCHECKBOX Follow-up needed: FORMTEXT ????? FORMCHECKBOX Other: FORMTEXT ????? FORMCHECKBOX Return in: FORMTEXT ?????Precautions or suggestions (for example, lighting conditions, activities to be avoided): FORMTEXT ?????Overview FORMTEXT ? Select the most appropriate statement. FORMTEXT ? FORMCHECKBOX This patient appears to have no vision. FORMCHECKBOX This patient does not have a serious visual loss after correction, in a clinical setting. FORMCHECKBOX This patient appears to have serious visual loss after correction, in a clinical setting. FORMCHECKBOX This patient has a diagnosis for a progressive medical condition that will result in no vision or a serious visual loss after correction.Eye Care Specialist Information FORMTEXT ? Signature of licensed ophthalmologist or optometrist:X FORMTEXT ?????Print or type name of licensed ophthalmologist or optometrist: FORMTEXT ?????Address: FORMTEXT ?????Date of examination: FORMTEXT ?????City: FORMTEXT ?????State: FORMTEXT ?????ZIP code: FORMTEXT ?????Telephone number:( FORMTEXT ???) FORMTEXT ?????Return completed form to: FORMTEXT ?Name: FORMTEXT ?????Address: FORMTEXT ?????Agency:Texas Workforce Commission FORMTEXT ?City: FORMTEXT ?????State: TX FORMTEXT ?ZIP code: FORMTEXT ?????This form should be used when an ophthalmological or optometric examination is conducted. It was developed by members of the Texas Education of Blind and Visually Impaired Students Advisory Committee, which consists of representatives from the following organizations: Texas Education Agency, Texas Workforce Commission Vocational Rehabilitation Services, Texas School for the Blind and Visually Impaired, Regional Education Service Centers, Texas Tech University, Stephen F. Austin University, Local School Programs, Deaf-Blind Multihandicapped Association of Texas, Texas Association of Parents of Children with Visual Impairments, Texas Association of Blind Students, National Federation of the Blind, American Foundation for the Blind, and Alliance of and for Visually Impaired Texans. 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