Republic of the Philippines

Department of Education
Region VII, Central Visayas
DIVISION OF CEBU PROVINCE

_____________________ DISTRICT
VISUAL ACUITY TEST RESULTS
School Year: ______________

SCHOOL: DISTRICT: DATE EXAMINED:

GRADE LEVEL: SECTION: TEACHER:

HEADACHE, READING RESULTS

NAUSEA, SQUINT
NAME OF LEARNER AGE SEX DIZZINESS WITHOUT REMARKS
WITH EYEGLASSES
EYEGLASSES
YES NO YES NO (R) EYE (L) EYE (R) EYE (L) EYE
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Checked By: Noted by:

CLASSROOM ADVISER SCHOOL CLINIC TEACHER

 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
DIVISION OF CEBU PROVINCE

_______________________DISTRICT
School Year :________________
SUMMARY VISUAL ACUITY RESULT
VISUAL ACUITY
HEADACHE / SQUINT
DIZZINESS NUMBER WITH EYEGLASSES
ENROLMENT NUMBER
RIGHT EYE LEFT EYE
GRADE LEVEL
M F M F READING NUMBER READING NUMBER
20 20 20 20 20 20 20 20 20
M F T Y N Y N
200 60 40 30 20 200 60 40 30
G7 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G8 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G9 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G10 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G11 SECTION:
SECTION:
 SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G12 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
ppines
UCATION
isayas
ROVINCE

___DISTRICT
_______
UITY RESULT
VISUAL ACUITY
ES WITHOUT EYEGLASSES TOTAL NUMBER
LEFT EYE RIGHT EYE LEFT EYE SCREENED
DING NUMBER READING NUMBER READING NUMBER
20 20 20 20 20 20 20 20 20 20 20
M F T
20 200 60 40 30 20 200 60 40 30 20
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
DIVISION OF CEBU PROVINCE

_______________________DISTRICT
School Year :________________
SUMMARY VISUAL ACUITY RESULT
VISUAL ACUITY
HEADACHE / SQUINT
DIZZINESS
NUMBER WITH EYEGLASSES WITHOUT EYEGLASSES TOTAL NUMBER
ENROLMENT NUMBER
RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE SCREENED
GRADE LEVEL
M F M F READING NUMBER READING NUMBER READING NUMBER READING NUMBER
20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20 20
M F T Y N Y N M F T
200 60 40 30 20 200 60 40 30 20 200 60 40 30 20 200 60 40 30 20
K SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G1 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G2 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
 SECTION:
TOTAL:

G3 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G4 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G5 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

G6 SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
SECTION:
TOTAL:

GRAND TOTAL
 Republic of the Philippines
DEPARTMENT OF EDUCATION
Region VII, Central Visayas
DIVISION OF CEBU PROVINCE

CONSOLIDATED SCHOOL REPORT OF THE VISUAL ACUITY RESULTS

School Year :_______________
Date Examined: ___________________

SCHOOL: DISTRICT:
VISUAL ACUITY RESULTS
HEADACHE / DIZZINESS
SQUINT TOTAL
WHEN READING
WITH EYEGLASSES WITHOUT EYEGLASSES NUMBER
GRADE/YEAR LEVEL SCREENED
NUMBER NUMBER RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
YES NO YES NO READING M F READING M F READING M F READING M F M F T
Grade 7 M F M F M F M F 20/200 20/200 20/200 20/200
ENROLMENT 20/60 20/60 20/60 20/60
M F 20/40 20/40 20/40 20/40
TOTAL: 20/30 20/30 20/30 20/30
TOTAL NO. WITH DEFECTS
TOTAL NO. WITH NORMAL VISION 20/20 20/20 20/20 20/20

HEADACHE / DIZZINESS VISUAL ACUITY RESULTS TOTAL

WHEN READING SQUINT
WITH EYEGLASSES WITHOUT EYEGLASSES NUMBER
GRADE/YEAR LEVEL SCREENED
NUMBER NUMBER RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
YES NO YES NO READING M F READING M F READING M F READING M F M F T
GRADE I M F M F M F M F 20/200 20/200 20/200 20/200
ENROLMENT 20/60 20/60 20/60 20/60
M F 20/40 20/40 20/40 20/40
TOTAL: 20/30 20/30 20/30 20/30
TOTAL NO. WITH DEFECTS
TOTAL NO. WITH NORMAL VISION 20/20 20/20 20/20 20/20

HEADACHE / DIZZINESS VISUAL ACUITY RESULTS TOTAL

WHEN READING SQUINT
WITH EYEGLASSES WITHOUT EYEGLASSES NUMBER
GRADE/YEAR LEVEL SCREENED
NUMBER NUMBER RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
YES NO YES NO READING M F READING M F READING M F READING M F M F T
GRADE II M F M F M F M F 20/200 20/200 20/200 20/200
ENROLMENT 20/60 20/60 20/60 20/60
M F 20/40 20/40 20/40 20/40
TOTAL: 20/30 20/30 20/30 20/30
TOTAL NO. WITH DEFECTS
TOTAL NO. WITH NORMAL VISION 20/20 20/20 20/20 20/20

HEADACHE / DIZZINESS VISUAL ACUITY RESULTS TOTAL

WHEN READING SQUINT
WITH EYEGLASSES WITHOUT EYEGLASSES NUMBER
GRADE/YEAR LEVEL SCREENED
NUMBER NUMBER RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
YES NO YES NO READING M F READING M F READING M F READING M F M F T
GRADE III M F M F M F M F 20/200 20/200 20/200 20/200
ENROLMENT 20/60 20/60 20/60 20/60
M F 20/40 20/40 20/40 20/40
TOTAL: 20/30 20/30 20/30 20/30
TOTAL NO. WITH DEFECTS
TOTAL NO. WITH NORMAL VISION 20/20 20/20 20/20 20/20

HEADACHE / DIZZINESS VISUAL ACUITY RESULTS TOTAL

WHEN READING SQUINT
WITH EYEGLASSES WITHOUT EYEGLASSES NUMBER
GRADE/YEAR LEVEL SCREENED
NUMBER NUMBER RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
YES NO YES NO READING M F READING M F READING M F READING M F M F T
GRADE IV M F M F M F M F 20/200 20/200 20/200 20/200
ENROLMENT 20/60 20/60 20/60 20/60
M F 20/40 20/40 20/40 20/40
TOTAL: 20/30 20/30 20/30 20/30
TOTAL NO. WITH DEFECTS
TOTAL NO. WITH NORMAL VISION 20/20 20/20 20/20 20/20
 HEADACHE / DIZZINESS VISUAL ACUITY RESULTS TOTAL
WHEN READING SQUINT
WITH EYEGLASSES WITHOUT EYEGLASSES NUMBER
GRADE/YEAR LEVEL SCREENED
NUMBER NUMBER RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
YES NO YES NO READING M F READING M F READING M F READING M F M F T
GRADE V M F M F M F M F 20/200 20/200 20/200 20/200
ENROLMENT 20/60 20/60 20/60 20/60
M F 20/40 20/40 20/40 20/40
TOTAL: 20/30 20/30 20/30 20/30
TOTAL NO. WITH DEFECTS
TOTAL NO. WITH NORMAL VISION 20/20 20/20 20/20 20/20

HEADACHE / DIZZINESS VISUAL ACUITY RESULTS TOTAL

WHEN READING SQUINT
WITH EYEGLASSES WITHOUT EYEGLASSES NUMBER
GRADE/YEAR LEVEL SCREENED
NUMBER NUMBER RIGHT EYE LEFT EYE RIGHT EYE LEFT EYE
YES NO YES NO READING M F READING M F READING M F READING M F M F T
GRADE VI M F M F M F M F 20/200 20/200 20/200 20/200
ENROLMENT 20/60 20/60 20/60 20/60
M F 20/40 20/40 20/40 20/40
TOTAL: 20/30 20/30 20/30 20/30
TOTAL NO. WITH DEFECTS
TOTAL NO. WITH NORMAL VISION 20/20 20/20 20/20 20/20

SUMMARY
TOTAL NO. WITH DEFECTS: MALE: FEMALE: TOTAL: TOTAL NO. SCREENED: MALE: FEMALE: TOTAL:
TOTAL NO. WITH NORMAL VISION: MALE: FEMALE: TOTAL: TOTAL ENROLMENT: MALE: FEMALE: TOTAL:

PREPARED BY: NOTED BY:

SCHOOL CLINIC TEACHER SCHOOL HEAD DATE: