Target Client List for Visual Acuity Screening, PPV and Influenza Immunization for Senior Citizens

No. Date of Assessment Family Serial Number OSCA ID No. Name Complete Address Sex Age
(mm/dd/yy) (Family Name, First name, Middle Initial) (M or F) (in years)

10

11

12

13

14

15
 Target Client List for Visual Acuity Screening, PPV and Influenza Immunization for Senior Citizens
Eye Complaints Visual Acuity With Eye Problem Pinhole Vision Management PPV Immunization Influenza Immunization
(blurred, floaters, tearing, (Write result as fraction) √ - if col 9 is √ & VA is > (for VA > 20/40) (Date given) (Date given)
blind spots, redness, 20/40 > 20/40 20/40 Improved No improvement Date referred to Date referred to an Ophthalmologist
X - if col 9 is X & VA is 20/40
photopsia, glare) Optometrist
(put √) (put √) If VA is 20/40 to 20/100 but If VA is 20/40 to 20/100 but did If VA is 20/200 or
√ - w/ at least one improved with pinhole not improve with pinhole worse

X – none of the above