Vision History (Usually completed by Primary Care Provider [PCP])
Parent concern, family hx, observed problems, sensitivity to lights, headaches,
squinting, hearing problems.
Ocular Health (PCP)
External inspection, Pupil light response, red reflex
Muscle Balance (PCP)
Visual Acuity (CMA)
One eye at a time
Age 3-5 years
Age 6 years and older
Pass: 20/30 or better without 2 line difference
Memorization Avoidance Techniques
E.g., to avoid memorization, hang chart on string and turn it over when ready to test or vary letters on each line. Screen in a distraction free area. Don’t isolate letters.
Document results such as distance from vision chart, behaviors, (i.e. head
tilt, squint) and history.
Family Hx or concern: Newborn hearing screening results, speech delays, risk factors for progressive and late onset hearing loss, e.g., Otitis Media (recurrent, >3 months with effusion), congenital eye or kidney problems, vision problems, head trauma, meningitis, rubella, etc.
Calibrate yearly; headphones calibrated specifically to audiometer. (C&TC
does not recommend handheld or Pilot audiometers.)
Not high traffic area, room intercom off, pass environment check
1000, 2000 and 4000Hz @20 dB
500 Hz @25 dB
Document results and screen level
Clean headphones. Use an alcohol free, 100% tuberculocidal, bactericidal,
fungicidal, and virucidal agent.
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