"Low Vision Evaluation (Lve) Pre-clinic Screening Questionnaire for Students in Georgia Schools" - Georgia (United States)

Low Vision Evaluation (Lve) Pre-clinic Screening Questionnaire for Students in Georgia Schools is a legal document that was released by the Georgia Department of Education - a government authority operating within Georgia (United States).

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Download "Low Vision Evaluation (Lve) Pre-clinic Screening Questionnaire for Students in Georgia Schools" - Georgia (United States)

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LOW VISION EVALUATION (LVE)
PRE-CLINIC SCREENING QUESTIONNAIRE FOR
STUDENTS IN GEORGIA SCHOOLS
(To be completed by school and parent & sent to low vision optometrists prior to the LVE)
Name:
Date:
DOB/Age:
Ocular diagnosis:
Reported acuities:
Distance: OD
OS
Intermediate: OD
OS
Near: OD
OS
Additional medical diagnoses/disabilities:
Date of most recent eye examination:
Eye doctor:
(Please attach most recent eye report)
Previous low vision evaluation:
YES
NO
If yes, date:
Page 1
LOW VISION EVALUATION (LVE)
PRE-CLINIC SCREENING QUESTIONNAIRE FOR
STUDENTS IN GEORGIA SCHOOLS
(To be completed by school and parent & sent to low vision optometrists prior to the LVE)
Name:
Date:
DOB/Age:
Ocular diagnosis:
Reported acuities:
Distance: OD
OS
Intermediate: OD
OS
Near: OD
OS
Additional medical diagnoses/disabilities:
Date of most recent eye examination:
Eye doctor:
(Please attach most recent eye report)
Previous low vision evaluation:
YES
NO
If yes, date:
Page 1
LVE-Pre-Clinic Questionnaire (Continued)
Person (s) completing this form:
Name of school:
TVI:
Grade:
Placement:
General education inclusion
Special education separate class
Primary language:
ESOL:
YES
NO
Primary mode of communication:
Speech
ASL
SEE
Object board
Picture symbols
Communication device - What kind:
Other- Explain:
Additional educational problems/disabilities:
Glasses:
Does the student wear his/her glasses?
YES
NO If yes, what task does the student use his/her
glasses to complete (Check all that apply:)
Near tasks (reading)
Intermediate tasks(Computer etc.)
Distance Tasks (to see board)
What is the prescription for the current glasses the student is wearing? (Attach script if available).
Page 2
LVE-Pre-Clinic Questionnaire (Continued)
Low Vision Devices/Accommodations currently using: (include working distance & tasks used for)
Optical:
Electronic:
Low tech:
Other:
Is the student a reader?
YES
NO
Is the student a non-reader?
YES
NO
If a reader, what is the student’s primary/secondary reading media?
Standard print
Primary
Secondary
Point size, font, and working distance:
Large Print
Primary
Secondary
Point size, font, and working distance:
Braille
Primary
Secondary
Auditory
Primary
Secondary
Lighting/ Glare Sensitivity
Page 3
LVE-Pre-Clinic Questionnaire (Continued)
Wears sunglasses to decrease light sensitivity?
Outdoors
Indoors
Wears a hat or visor to decrease glare?
Outdoors
Indoors
Uses special or task lighting?
YES
NO
Uses colored overlays?
YES
NO
Visual Fatigue: Describe visual fatigue if it applies and when it occurs:
VISUAL TASKS
Use the following key to indicate the appropriate statement for each task below:
N/A =Not Applicable
N=Not a problem
M=Mild problem
Y=Major Problem
O= Patient/student desired outcome
READING
Headlines
Large Print (textbooks, general reading & what point size & at what distance)
Standard print (textbooks & general reading)
Newspapers
Magazines
Maps/graphs/line drawings
Photographs & illustrations
Price tags/ labels
Low contrast text/fonts
Cursive writing
Page 4
LVE-Pre-Clinic Questionnaire (Continued)
Menus
WRITING
Signing name
Manuscript writing
Cursive writing
Completing forms/ worksheets
Preferred writing accommodation(s):
Slant board
Bold line paper
Bold marker/pencil
DISTANCE TASKS
Recognize gestures
Recognize nonverbal communication
Seeing information for group viewing (Auditorium presentations, demonstrations,
chalkboard, whiteboard, videos, computer projections, etc.)
Seeing poster, bulletin board, wall menus, etc.
COMPUTER
Seeing the computer screen
Finding the cursor on the screen
Using the mouse
What computer adaptations do you use and does it help?
Screen magnification software
Does its help?
YES
NO
Adaptive Screen placement
Does its help?
YES
NO
Screen reader software
Does its help?
YES
NO
Glare control (What type?)
Does its help?
YES
NO
Adaptive keyboard
Does its help?
YES
NO
Working distance from the keyboard:
Page 5
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