Illinois Administrative Code
Title 77 - PUBLIC HEALTH
Part 665 - CHILD AND STUDENT HEALTH EXAMINATION AND IMMUNIZATION CODE
Subpart F - EYE EXAMINATION
Appendix A - Illinois Department of Public Health Eye Examination Report

Universal Citation: 77 IL Admin Code ยง A
Current through Register Vol. 48, No. 12, March 22, 2024

State of Illinois

Eye Examination Report

Illinois law requires that proof of an eye examination by an optometrist or physician (such as an ophthalmologist) who provides eye examinations be submitted to the school no later than October 15 of the year the child is first enrolled or as required by the school for other children. The examination must be completed within one year prior to the first day of the school year the child enters the Illinois school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.

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To Be Completed By Examining Doctor

Case History

Date of Exam:

_________________________________

Ocular History:

[] Normal

or Positive for:

_________________________

Medical History:

[] Normal

or Positive for:

_________________________

Drug Allergies:

[] NKDA

or Allergic to:

_________________________

Other Information: ___________________________________________________

___________________________________________________________

Examination

Distance

Near

Right

Left

Both

Both

Uncorrected Visual Acuity:

20 /_______

20 /_______

20 /_______

20 /_______

Best Corrected Visual Acuity:

20 /_______

20 /_______

20 /_______

20 /_______

Was refraction performed with dilation?[] Yes [] No

Normal

Abnormal

Not Able

to Assess

Comments

External Exam (lids, lashes, cornea, etc.)

[]

[]

[]

_________________

Internal Exam (vitreous, lens, fundus, etc.)

[]

[]

[]

_________________

Pupillary Reflex (pupils)

[]

[]

[]

_________________

Binocular Function (stereopsis)

[]

[]

[]

_________________

Accommodation and Vergence

[]

[]

[]

_________________

Color Vision

[]

[]

[]

_________________

Glaucoma Evaluation

[]

[]

[]

_________________

Oculomotor Assessment

[]

[]

[]

_________________

Other: _____________________

[]

[]

[]

_________________

NOTE: "Not Able to Assess" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.

Diagnosis

[] Normal

[] Myopia

[] Hyperopia

[] Astigmatism

[] Strabismus

[] Amblyopia

Other: _____________________________________

Recommendations

1.

Corrective Lenses:

[] No

[] Yes, glasses or contacts should be worn for:

[] Constant Wear

[] Near Vision

[] Far Vision

[] May Be Removed for Physical Education/Recess

2.

Preferential Seating Recommended:

[] No

[] Yes

Comments:

___________________

3.

Recommend Re-examination:

[] 3 months

[] 6 months

[] 12 months

[] Other

4.

________________________________________________________________

5.

________________________________________________________________

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Disclaimer: These regulations may not be the most recent version. Illinois may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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