Early Childhood/C&TC Vision Screening Worksheet
pPrinter-Friendly Version (PDF: 143KB/pages)NAME: __________________________________________
AGE:__________ Yrs. ____________ Mo.
DATES:__________________________________________
| (If child is under age 3 years, see "My child's vision checklist" tool) | SCREEN | RESCREEN | ||
|---|---|---|---|---|
| Pass | RS | Pass | Refer | |
| Does child have glasses or contacts? | ||||
| Wearing them during screening? | ||||
| Problem Noted: | ||||
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A. External Inspection (Birth and older) WIPL |
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B. Observation (2 months – 3rd grade) |
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C. Corneal Light Reflection (2 months – 3rd grade) |
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D. Cross Cover Test (4 months – 3rd grade) |
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E. Color Vision (1st grade males; others optional) |
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F. Visual Acuity (Age 3 as early as possible) |
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G. Optional Plus Lens (No Rx and pass all other procedures) |
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H. Optional Stereopsis Test (3 years to 3rd grade) |
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I. EOM/Fix and Follow Binocular (2 months until V.A.) |
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J. EOM/Fix and Follow Monocular (2 months until V.A.) |
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K. Pupillary Light Response (birth until V.A.) |
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L. Retinal Reflex (birth until V.A.) |
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VISION HISTORY AND QUESTIONS – ALL AGES
| NO | YES | |
|---|---|---|
| 1. Do you suspect anything is wrong with your child’s eye/vision? | ||
| 2. Have the child’s siblings, parents, grandparents, aunts, uncles, or first cousins had eye/vision problems that required treatment before entering school?. (example: strabismus [crossed eyes] or amblyopia [lazy eye], wore glasses). | ||
| 3. Was the child born premature or had retinopathy of prematurity? | ||
| 4. Is there a family history of congenital cataracts, retinoblastoma, metabolic or significant development delay? | ||
| 5. Have you observed any problems or change in the whites, pupils, lids, lashes or the area around the eyes? | ||
| 6. Have you noticed an abnormal sensitivity to light, nausea or dizziness or signs/complaints of headaches? | ||
| 7. Have you noticed any of the following? | ||
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a. Turning of one eye (in, out, up or down) either occasionally or always |
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b. Poking at the eyes or frequent rubbing |
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c. Poor eye contact |
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d. Covering or closing an eye when looking at an item of interest |
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e. Abnormal head posture |
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f. Squinting |
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g. Moving the head forward, backward or on the horizontal while looking at an item of interest |
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h. Tilting head to one side |
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i. Placing head close to item of interest |
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j. Excessive blinking |
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k. Inaccurate in reaching for item of interest |
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l. Unusual tearing |
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m. Do both of the child’s eyes appear the same in pictures |
