Early Childhood/C&TC Vision Screening Worksheet

Printer-Friendly Version (PDF: 143KB/1 page)

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:

A. External Inspection (Birth and older) WIPL

       

B. Observation (2 months – 3rd grade)

       

C. Corneal Light Reflection (2 months – 3rd grade)

       

D. Cross Cover Test (4 months – 3rd grade)

       

E. Color Vision (1st grade males; others optional)

       

F. Visual Acuity (Age 3 as early as possible)
Screen age 3-5 yr: R 10/__ L 10/__ Re-screen: R 10/__ L 10/__
Screen age 6+ yr: R 20/__ L 20/__ Re-screen: R 20/__ L 20/__

       

G. Optional Plus Lens (No Rx and pass all other procedures)
+2.25 (1st-3rd grades) +1.75 (4th grade and up)

       

H. Optional Stereopsis Test (3 years to 3rd grade)

       

I. EOM/Fix and Follow Binocular (2 months until V.A.)

       

J. EOM/Fix and Follow Monocular (2 months until V.A.)

       

K. Pupillary Light Response (birth until V.A.)

       

L. Retinal Reflex (birth until V.A.)

       

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?

a. Turning of one eye (in, out, up or down) either occasionally or always

   

b. Poking at the eyes or frequent rubbing

   

c. Poor eye contact

   

d. Covering or closing an eye when looking at an item of interest

   

e. Abnormal head posture

   

f. Squinting

   

g. Moving the head forward, backward or on the horizontal while looking at an item of interest

   

h. Tilting head to one side

   

i. Placing head close to item of interest

   

j. Excessive blinking

   

k. Inaccurate in reaching for item of interest

   

l. Unusual tearing

   

m. Do both of the child’s eyes appear the same in pictures