DELAWARE HEALTH AND SOCIAL SERVICES
DIVISION FOR THE VISUALLY IMPAIRED
1901 N. Dupont Highway, Biggs Building
New Castle, DE 19720
Phone: (302) 255-9800
Fax: (302) 255-9921

EYE REPORT FORM

Dear Doctor:  In order for DVI to provide services to the patient noted below,
we require the following information from you.  Please return the completed form
to DVI, Attention: DVI Intake.  Thank you.

Please type or print clearly.

PATIENT NAME: ____________________________________	Date of Birth: _____________

	Address: ____________________________________________________________

	City, State, Zip Code: ___________________________________________________

	Phone: _______________________  Social Security Number: ___________________


DIAGNOSIS (Eye Condition Primarily Responsible for Vision Impairment)

Right Eye: _____________________________	Left Eye: _____________________________


CENTRAL VISUAL ACUITY WITH CORRECTION (Distance at 20' )

Right Eye: _______________________	Left Eye: ____________________________


FIELD LIMITATIONS
Type of Field Test (If Completed): ______________________________________
(Please attach a copy of the field test.)

Right Eye: _______________________	Left Eye: ____________________________


DATE OF MOST RECENT EYE EXAMINATION: _____________________


VISUAL CATEGORY (Please select one of the following visual categories):

___ Totally Blind (No Light Perception)
___ Legally Blind (20 / 200 visual acuity in the better eye with correction OR,
	has a field restriction of 20 degrees or less)
___ Severely Visually Impaired (20 / 70 visual acuity in the better eye with correction)
___ Visually Ineligible (The person does not match one of the above three categories)


EXAMINING PHYSICIAN (Printed): __________________________________  Date: ___________



EXAMINING PHYSICIAN (Signature): __________________________________

Form DVI IU-02
Revised June 2004