NATIONAL VISION SCREENING PROGRAM

FOR KINDERGARTEN STUDENTS

REFERRAL FORM
Name of Patient: Date Accomplished:
Birthday: Age: Civil Status: Sex: M F
Nationality: Contact Number: Occupation:
School/ Home Address:
Criteria: 4Ps IPs PWD Indigent _______________ (attach certificate)

Please check if present upon screening.

I. APPEARANCE YES NO REMARKS
Crossed-eyes or misaligned eyes
Shaking eyes or eyes in constant motion, i.e., nystagmus
Red eyes
Watery eyes/ with eye discharge
Drooping eyelid(s)
Presence of a white pupil
Eye injuries resulting in bruising, swelling or bloodshot eyes
Lumps/ growths
II. BEHAVIOR YES NO REMARKS
Squinting, frowning, blinking or squeezing the eyes
Thrusting head forward, or backward while looking at
distant objects
Rubbing the eyes
Turning the head
Placing the head close to a book or a desk when reading or
writing
Closing or covering one eye, especially in bright light
III. COMPLAINTS YES NO REMARKS
Eye Pain
Burning, Scratchy or Itchy Eyes
Blurred Vision
Double Vision
Unusual sensitivity to light
Headaches
Nausea & Dizziness

VISUAL ACUITY DISTANCE (ft) RIGHT EYE LEFT EYE REMARKS

TEST
Far
Near
OPTOMETRIST/S REPORT Date:
Findings/Diagnosis:
Recommendations:

Final Refraction if any:

Name and Signature of Eye Care Practitioner:

REFERRAL SLIP Date:

Patient’s Name: Age: Sex:
Findings/Diagnosis:
Recommendations:

Name and Signature of Eye Care Practitioner: