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 (Text-Only version) DVI Form Number: DVI IU-02 Form Revised: February 2010 Please see instructions for completion at the end of this document. Dear Doctor: In order for DVI to provide the best service to the patient noted below, we request the following information from you. Please return the completed form to DVI, Attention: DVI Intake. Thank you. Please type or print clearly. SECTION 1: Patient Demographic Information ------------------------------------------ Name: ____________________________________ Date of Birth: _____________ Street Address 1:_______________________________________________________ Street Address 2:_______________________________________________________ City, State, Zip Code: ___________________________________________________ Phone Number: _______________________ Social Security Number: ___________________ SECTION 2: Patient Medical Information -------------------------------------- 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 four following visual categories with an "X"): 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 Signed: ___________ EXAMINING PHYSICIAN (Signature): __________________________________ Section 3: Instructions for completing Eye Report Form ------------------------------------------------------ We appreciate your cooperation in completely entering the information on the form. Accurate information allows us to provide better and more efficient service to your patients and our consumers. It also enables DVI to maintain an accurate Registry. If you have questions about the proper completion of this form, please contact central intake, 302-255-9848 or 302-424-8638. Instructions: 1. Please type or print clearly all the Patient Data information. Please ensure correct spelling of name, current address and phone number, accurate birth date and social security number. 2. Include a diagnosis. 3. Include correct distance acuity for each eye. 4. If a field test was completed, include a copy of the test. Please also note the degree of the field loss. 5. If no field test was completed, please note N/A in the Field Limitations Section. 6. Include the date of the examination. 7. Check the appropriate visual category using the definitions provided. Please note on the form if the consumer is legally blind by a field restriction rather than by visual acuity. 8. Please be sure that the form is signed and dated by the Examining Physician along with his/her typed or printed name. Thank you.