Vision screening form template

About this vision screening form

Schools, eye camps and community health programs run vision screening to catch children and adults who need a full eye examination. This form records visual acuity for each eye with and without glasses, symptoms such as squinting or headaches, colour vision, the outcome and whether the family was notified about a referral.

Screening isn’t a diagnosis; anyone who doesn’t pass should see an optometrist or ophthalmologist.

What’s on the vision screening form

The template has 3 sections and 13 questions. Every one can be renamed, moved or deleted.

• Person screened: Name; Age; Class / grade; Date; Screener; Chart used
• Results: Acuity table (Eye, Without glasses, With glasses); Wears glasses (yes or no); Symptoms (tick all that apply: Squinting, Headaches, Eye rubbing, Holds books close, Watery eyes, None); Colour vision (choose one: Normal, Possible deficiency, Not tested)
• Outcome: Result (choose one: Pass, Refer for full eye exam, Re-screen); Notes; Parent notified on

Tips

• Test each eye separately at the distance your chart requires.
• Record the chart used (e.g. Snellen, LogMAR, tumbling E).
• Send referral notes home the same day.

Four ways to save it

A fillable PDF has typing boxes, tick boxes and choices built in. A printable PDF gives clean boxes and writing lines for pen and paper. The Word file can be edited further, and the HTML code adds the same questions to a website. Browse more form templates, or design a completely different layout in the custom form builder.