<)> SANKARA EYE FOUNDATION SANKARA EYE HOSPITAL Varthur Main Road, Kundalahalli Gate, Bangalore - 560 037. Ph. : 080 69038900 / 01 / 02 / 03 L Name: Kin Knute Mallon MRNo: “1493 S) Age/Gender: 2.2 ayle Date of Birth: ate: 2| 412 3Referred By: Dw TH Wa serena screed by, ~facthers cesar ong: (OO )Sadigandt’® digihagley [Rd tone Aaephy LOW VISION - INITIAL ASSESSMENT Date of First Diagnosis: 2-00 © - Diagnosis Made At: H/\cur. bat Duration of vision les: |=} en, Stbilty of slo: 1. Worse €stabi93. improved Has the vision changed in last 6 months? Yes (No) Ifyes, specify PERSONAL HISTORY: Education | Occupation Marital Status | Co-operation from work place Graduate] Sbded T Ou wennedt Awernie ‘Areyouthe | Support Dependents | Lterary | Economie | Occupational | Financial bread-winner Status of Status of status of Support of the family? parents/ Family : parents / provided guardian guardian by Yes /fo nt i _ Grocat| Above | Speco | pict lependent avenge: | Contech dependent tiving ; FAMILY HISTORY: eine Family history of Family history of | Details of Family History . visual problems ‘ther problems No. Nal ALO. Nal - Additional Disabilities : Physical Hearing Speech Disability] Intellectual Other Disability Disability Disability Disability Aue KUL NAL Nine izPREVIOUS USE OF DEVICES: Previous Low Vision Care: Yes (No )f yes, specify where and when: Current and last used | Duration (hours | Time since Present | Satisfaction | Device | Comments devices : per day) purchase (months) | condition | with use of | brought| ofdevice | device _| today Spectacles lo- by | S yer [Awe 6 Kayes |- —+ \ \ r Contact Lenses Low Vision Devices N\ 1 \ 2 3 DISTANT VISION TASKS: Do you have difficulty in any of the following? a,]Recognizing face] 2. Watching TV at a distance 3. Reading bus numbers 4. Copying a chalk board ? - 5. Watching movies in theatre 6. Driving or riding a motor vehiclé_7(Following computer presentations ene 8. Sightseeing 9. Others < plosfing, exsc Ket INTEF TE VISION Do you use computer Use(Ves)/ No Preferred font size:Purpose of using computers: 1. Communication 2. Profession 3. Education 4. RecreationDo you have difficulty in any of the following while using computers? {-) 1. Reading print on the monitor? 2. Glare from the monitor 3. Recognizing keyboard letters/symbols NEAR VISION TASKS: 's reading a priority? Vep/ No Is reading a difficult task? Yes Purpose Of Reading: 1. Education 2. Occupation 3. Religious 4. Recreation 5. Other Do you have difficulty while reading any of the following? 1. Textbooks 2. Newspaper 3. Religious books 4. Dictionary 5.Price bills 6. Medicine labels 7. Others: Can you manage to read at a closer distance? Yes /No 1s writing a Priority? Fey No oa Purpose of Writing. Education 2. Occupation 3. Religious 4. Recreation 5. Other Do you have difficulty in writing along a straight line? Vex) PREFER! JMINATION: ) Mlumination Source: Fluorescent Light 2. Incandescent Light 3. Natural Light 4. Other Z-indirect Light 3, Reduced Light 4. Other Qa IMumination Quality: 1. Bright Light 2. UGHT SENSITIVITY: Do you have problem with glare in outdoors? Yes, () : Source Of Glafe: 1. Sunlight 2. Bright Artificial Lights 3. Vehicle Lights From Opposite Direction 4. ‘Are you using preventive measures for glare? Yes / No Preventive Measure: Delayed adaptation: 1. From bright surrounds to dark 2. From dark surrounding to bright? MOBILITY HISTORY: Do you have any difficulty in mobility? Y¢é/No Do you take help from others for your mobility? Yes/No _f yes, help fro others: ther: Peaked Cap 2. Dark Glasses 3.Tinted Lenses 4. Photochromic Lenses 5. Filkers 6. Other:Description of Problem : SI. No. Specific Problems Familiar | Unfamitiar Day Night 1_| Ascending stairs 2 | Descending Stairs 3 | Bumping into Objects 4 | Crossing Roads 5 | Others a 2 DAILY LIVING SKILLS: ts there a difficulty in performing activities of daily living? Yes/No Difficulty 1. Grooming: 1. Bathing 2.Using the Toilet 3. Dressing 4.Matching Clothes 5. Identifying the Correct Side 6, Other: I. Kitchen and Eating Skills: 1. Identifying Groceries 2. Measuring Quantity 3. Separating Stones from Grain 4. Cutting Vegetables 5.Pouring Liquids 6.Food Identification 7.Other: Ul, Housekeeping: 1. Cleaning the House 2. Arranging Cupboards 3. Making the Bed 4. Other: IV. Miscellaneous: 1. Threading a needle 2. Identifying Items on shelves 3. Currency note identificat y 4. Coin Identification 5 Color differentiation) 6. Telling Time 7. Others: ae BRIEF CURRENT MEDICAL HISTORY: Chief Complaints: Clo Graduat Dov mm BE doe dyst smce eyes a ec. ‘es GROSS VISUAL BEHAVIOUR: Visual Fixation: Ocular Preference: Right / Left (Both Unknown DISTANCE VISUAL ACUITY: E Distance Vision Chart Used: | MAR | distance of chart: Zurn _ Illumination for chart: R oe. > TUltemdoroh@Unaided Vision : Aided Vision : LCVA ‘HCVA LCVA HCVA L Right Eye 0-4 LoS ovap_| Right Eve 0 Bosmab| Left Eye O.1B2 Lee. Left Eye D abl eeme Both Eye Both Eye Current Distance Prescription : L ‘Sphere Cylinder Axis zl Right Left Near Add Near Vision (Both eyes): NO FO om, using PPS chart undecO2~*~ ittumination. Type of Spectacle: 1, Single Vision 2. Bifocal 3. Progressive Frame Shape:. _, Type of Bifocal: ., Frame Materia} : REFRACTION : ee Dry Retinoscopy Dry Acceptance | ‘Sph cyl Axis Sph cyl Axis Distance Near Near Vision Add Vision Right | 12.Se | 2.0] (WO | 42:00]-2-50 ] t10 | Ola0 fs Eye @200r4 ened eqs [0-50] WO [-te-00 [ose [10 6 loupe Se |Cycloplegic Used : Atropine / Homatropine / Cyclopentolate / Tropicamide / Other Cycoplegc Retraction Cyeloplegic Acceptance sh | cw [ans | som] oy | ams | ditonce van wight tye Left Eye} ‘VISUAL FIELD TESTIN Humphery’s Visual Field (30- Confrontation Test 2) other \R2 Om metry Right Left Right Left Right Left CINICA)_* [fe LT LT = | “Ps 7 “te Humphery's Visual Field (10- Amslers Chart 2) Other Right Left Right Left Right Left Color Vision: 15 Contrast Sensitivity Right Left Right Left Ter le FO at COT” Te —p en ee PP ay plocte d.soleees | 4. BeleSeg. BINOCULAR FUNCTION: stereopss: Worth 4-dot Test: TRIAL OF LOW VISION DEVICE: : Magnification Required: GX _ Preference for: Right / Left / Both EyesTrials: a Nioth 4 tueepe Hx 0.) toy ng 2 Myo MH elope. Sx Solog HOR > See WV = 624 fog tae 4. Preferred Device: lo we *clocope ae Visual Skills: Fixation: Gog ‘Average / Poor : Good / Average / Poor Scanning: Goo Average / oor Tracking: Gopd/ Average / Poot Nearvision devices: EvP= (2+ 3f) Preference for: Right / Left / Both Eyes Trials: 1 ; Nek se Qyuioed || 4 Preferred Device: Visual Skills: Good / Average / Poor Visual Objective Fulfilled: Yes/No Reasons for non- fulfillment of visual objectives: 1 Severe Visual Impairment 2.Poor Literary Skills 3. Peripheral Field Loss 4. Mismatch of Task B: LVDs 5.Poor Co-Operation 6. Multiple Disabilities 7. Not Motivated 8. Others. Preference of Absorptive Lenses: 1.DarkGrey 2.Light Grey 3.Dark Yellow 4. Light Yellow 5.Dark Brown 6. Light Brown 7. Others,{OW VISION REHABIUTATION PLAN AND MANAGEMENT: [Panu Rx Be, “ekeeral FO 18.0 Vn ie Problem Summary Pakent & a%ylmab Gmete CBnie coite, Rem A 0-82 lg HmRs, op Ac Od logHmR nok” Nas Ui dua obsity Ni @ dooms An 00 GEES UINen jLe iA not able *% Opprevokt Alorno plats abo. . a5 le ca Conti nonstivity A 1 -SS WES i onde 185 Ie in of + Terk di Bree ed ae dur to ky ViNion- Management Plan Z Coggateh opticel dauicn PRESCRIPTION: Optical Devices Suggested: stance To Mle Mt Adletape Mt: Near Task: (No heed es Meh: ‘Non-Optical Devices Suggested: IO Other Devices Suggested: Motivated to Use LVDs: Not Applicable / YeS/ No IfNo, Specify: 1. Cost 2. Cosmetic Blemish 3. Handling Problems 4. Not Matching With Tasks 5. Wants To Decide Later 6. Can Manage With their Own LVDs _7.Others: WWDs purchased: Yes/ a Source suggested Cross Consult to Other Department: ‘Next Appointment: Examiner's Name & Sign: Aioray [wu cate] Pon'uctla