Vision Screening Results

 
Distance Eye Chart ( at 10 feet)
Right eye 20/_________              Left eye 20/__________      Both eyes 20/_________

Near Vision Chart (at 16 inches)
Right eye 20/_________              Left eye 20/__________      Both eyes 20/_________

Color Screening
Right eye ________ of 4                 Left eye ___________ of 4

Stereo Screening
______________ of 9

Eye Muscle Movement

Comments: _______________________________________________________________________

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