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The Hadley School for the Blind

EYE REPORT

To the U.S. student/applicant:
Please mail or take this form to your physician or eye specialist.

To the physician or eye specialist:
Please indicate patient's visual acuity and/or peripheral field and provide the information requested below.

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Patient's name

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Address

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City, State, Zip

    O.D. O.S.
Visual acuity (best corrected, for distance) ______ ______
Visual field ______ ______
Totally blind ______ ______
Light perception ______ ______
Object perception ______ ______
Hand movements ______ ______
Counts fingers ______ ______

1. Does this patient meet the standard definition of legal blindness?

Yes___ No___

2. Condition is considered to be:

Progressive___ Stable___ Capable of improvement___ Uncertain___

3. Diagnosis (each eye):

______________________________________________________________________________

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Physician or eye specialist's name

______________________________________________________________________________
Address

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City, state, zip or postal code

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Area code and telephone number

RETURN PROMPTLY TO:

The Hadley School for the Blind
Student Services Department
700 Elm Street
Winnetka, IL 60093-0299
Telephone 847-446-8111
Fax 847-446-0855

 

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Physician's or eye specialist's signature

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Date