Nurse-Led Pediatric Vision Screening
Patient Information
Full Name
Date of Birth
Age
Gender
Male
Female
Other
Parent/Guardian Name
Screening Details
Date of Screening
Screened By (Nurse Name)
Reason for Screening
Vision Screening Results
Right Eye (OD) Visual Acuity
Left Eye (OS) Visual Acuity
Both Eyes (OU) Visual Acuity
Screening Method
Snellen
Lea Symbols
Tumbling E
Other
Other Findings / Observations
Referral & Follow-Up
Referral Needed
Yes
No
Comments/Notes
Signature
Nurse Signature
Date