VISION SCREENING FORM

Name of School:___________________________________________________________________________
Section:__________________________________________________________________________________
Province: ( ) Quezon ( ) Orien. Mindoro ( ) Antique ( ) Neg Or

NAME of CHILD: _________________________________________________________________________

DATE OF BIRTH: ______________________________________ AGE:________ SEX: __________

PLEASE CHECK THE APPROPRIATE ANSWER:

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)

Droopy Lids (kirat) ( )Yes ( )No

Red eyes (pula ang mata) ( )Yes ( )No
Watery eyes (luha ng luha) ( )Yes ( )No
Eye discharge (madaming muta) ( )Yes ( )No
Eyes not aligned (duling o banlag) ( )Yes ( )No
Eyes have opacity (may puti ang mata) ( )Yes ( )No

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)

Visual Acuity (without eyeglasses)

Both eyes open: ___________ Right Eye: ____________ Left Eye: ____________

Visual Acuity (with eye glasses)

Both eyes open: ___________ Right Eye: ____________ Left Eye: ____________

Child needs further referral to an Ophthalmologist? ( )Yes ( )No

If yes, consent of parent/guardian accomplished needs to be taken.

Signature over Printed Name of Screener Date accomplished