Professional Documents
Culture Documents
Vision Screening Form 1
Vision Screening Form 1
Name of School:___________________________________________________________________________
Section:__________________________________________________________________________________
Province: ( ) Quezon ( ) Orien. Mindoro ( ) Antique ( ) Neg Or
HISTORY:
Has the child been seen by an ophthalmologist? ( )Yes ( )No
Optometrist? ( )Yes ( )No
Child wearing glasses? ( )Yes ( )No
Child has special needs or syndrome? (Autism, Down’s etc.) ( )Yes ( )No
APPEARANCE OF THE EYE: (Use flashlight or penlight to check the child’s eye. If there is a YES answer,
please refer to an Eye Doctor.)
(Gamitin ang ilaw ng flashlight o penlight upang makita ang mata ng bata. Kung may sagot na YES, ipakita ang
bata sa doctor sa mata)
VISUAL ACUITY: (by the School Nurse/Optometrist) Use the provided eye chart at the proper distance.
Allow the child to wear his/her glasses if he/she has one. Check with both eyes open first, then cover left eye to
check for the right eye. Lastly, cover the right eye to check for the left eye. Please refer the child to an
Ophthalmologist accordingly for a complete eye exam.
(Gamitin ang chart sa tamang layo mula sa bata. Ipagamit ang salamin kung may suot na. Unahin pabasahin ang
parehong mata ng walang takip. Kasunod ay takpan ang kaliwang mata upang makabasa ang kanan.
Pagkatapos, takpan ang kanang mata upang makabasa ang kaliwa. Ipakita ang bata sa eye doctor kung
kinakailangan para sa isang kumpletong eye exam)