NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Commission for the Blind

LOW VISION EVALUATION REPORT

THIS SECTION TO BE COMPLETED BY COUNSELOR OR PRIVATE AGENCY CASE MANAGER

Client's Name: (First, MI, Last)

Client's Address:

Client's Date of Birth: ex: 03/22/1959

Counselor's/Case Manager's Name:

Office Location:

PROPOSED CLIENT ACTIVITIES (If known) OR SPECIFIC COUNSELOR'S CONCERNS: Include relevant information on client's living situation, ability to travel independently, health status, motivational level, etc.

THIS SECTION TO BE COMPLETED BY LOW VISION SPECIALIST

FIELDS
Constricted
Hemianopic
Full
Scotoma

ENTERING CORRECTED VISUAL ACUITY
DISTANCE O.D. O.S. O.U.

NEAR O.D. O.S. O.U.

DIAGNOSIS

RECOMMENDED OPTICAL DEVICES

Codes/Fees: Description:

Anticipated Visual Acuity: Use:

Codes/Fees: Description:

Anticipated Visual Acuity: Use:

Codes/Fees: Description:

Anticipated Visual Acuity: Use:

Codes/Fees: Description:

Anticipated Visual Acuity: Use:

TOTAL:

Narrative Report: (include information on tasks to be performed, client's acceptance of devices, special conditions required, such as lighting, posture, time restrictions, etc.)

DATE OF INITIAL EXAMINATION ex: 03/22/2011

DATES OF FOLLOW-UP VISITS ex: 03/22/2011

RESULTS OF FOLLOW-UP VISITS:

SPECIALIST'S NAME AND ADDRESS:

SPECIALIST'S SIGNATURE:

DATE: ex: 03/22/2011

ADDITIONAL COMMENTS: