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Get the free Vision Screening Fact Sheet - ECLKC - HHS.gov

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Instruction Manual Vision Screening with the VSV Vision ScreenerModel #1155www.keystone view. Division OF MAST CONCEPTS, INC. 1Contents VSV: Features and Capabilities. . . . . . . . . . . . . . .
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How to fill out vision screening fact sheet

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Step 1: Obtain a vision screening fact sheet from your healthcare provider or download it from a reliable source.
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Step 2: Begin by filling out the personal information section, including the individual's name, date of birth, and contact information.
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Step 3: Move on to the medical history section and provide details about any previous eye conditions, surgeries, or family history of vision problems.
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Step 4: Fill in the section about current symptoms or concerns regarding vision. Include any difficulties with reading, distance vision, or other visual impairments.
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Step 5: Answer the questions regarding previous vision screenings, glasses or contact lens use, and any vision-related accommodations or treatments received.
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Step 6: Complete the section on visual acuity by accurately recording the results of the screening tests, if applicable.
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Step 7: Finally, review the completed form for any errors or missing information before submitting it to the appropriate healthcare professional.
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Step 8: Make copies of the filled-out vision screening fact sheet for your own records if desired.

Who needs vision screening fact sheet?

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Anyone who is undergoing a vision screening or evaluation may need to fill out a vision screening fact sheet. This includes individuals of all ages, from infants to older adults. The form helps healthcare professionals gather important information about a person's eye health history, symptoms, and any previous vision-related treatments or accommodations.

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