School Age Vision Referral Letter

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Regarding _____________________________________

Dear Parent:

In keeping with the recommendations of the Minnesota Department of Health, your child was screened ____/____/____ and rescreened ____/____/____.

You are urged to take your child for a professional eye examination for the reason(s) checked below:

( ) Complaints of visual distress, observed behaviors
( ) External eye problems
( ) Possible eye muscle problems
( ) Did not read lines on chart appropriate for age group
(with) (without) glasses Right __/__ Left __/__
( ) Farsightedness
( ) Fusion/suppression problems


Please take this form with you when your child is examined and ask the examiner to complete the bottom half.

Dear Doctor:

Please complete this portion of the form and send it at your earliest convenience to:

(School Nurse) _______________________________________________________
____________________________________________________________________
____________________________________________________________________

I have examined___________________________________ on __/__/__.

I feel the eye problem is:

( ) Not sufficient to require treatment
( ) Fully treatable
( ) Partially treatable
( ) Not treatable
( ) Glasses prescribed
Best Correction: Right __/__ Left __/__
( ) Lens changes
Best Correction: Right __/__ Left __/__

Vision defect:

( ) Muscular
( ) Myopia
( ) Hyperopia
( ) Astigmatism
( ) Suppression
( ) Fusion defect
( ) External eye disease
( ) Other _________________________

I expect that on completion of whatever treatment is necessary there will be:

( ) No significant visual handicap that may interfere with learning.
( ) Visual handicap that may interfere with learning.

Child should return for follow-up examination on __/__/__.

Special recommendations: ____________________________________________________________________
____________________________________________________________________

Signed __________________________________________

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