ABCD logo

Alaska Blind Child Discovery

A cooperative, charitable research project to vision screen every preschool Alaskan

2020 Telemedicine Home Report



Patient’s First Name:?_________________________ Last Name:____________________________
Birthdate: m______/d________/y__________ Today’s date ____/_____/_________
cell phone # (_______)________-_________ email:______________________________________
Name of ( )parent / ( )guardian or ( )who is sending the Telemedicine Exam: ___________________

Health History:

Main Problem/Concern with Vision:___________________________________________________
When did it start?______________________________________
How bad is it?_________________________________________
What makes it worse?___________________________________
What makes it better?____________________________________

( )New Referral or ( )Follow-up
Your doctor / local health-care provider(s)? ____________________________________

Any current treatments for the eye(s)?____________________________
Glasses?: _________________

Any other Health Problems?:

Any "Warning Signs?"

Explain any Injury to the eyes?____________________________

Any Surgery related to the eyes?_______________________

Any Family Vision problems related to the eyes?__________________

Your Examination of the EYES and VISION:

Home Acuity Monitor : right eye: 20/_________ left eye: 20/__________

If you can get a photoscreen from local clinic / nurse / Lion’s Club, send results.

Download Home Exam Guide and tape to patient's neck

Cell phone photograph(s) showing what concerns you about the eye(s).

Cell phone video showing eye alignment or concerns.

( ) Video or observation of Cover Test:

( ) Both index fingers estimate Intraocular Pressure (IOP of a Grape video): _____ R_______ L


ABCD History
Kids Eye Disorders
Vision Screening
ABCD Clinics
Contact ABCD
Alaska Children's EYE


Home | ABCD History | Pediatric Eye Diseases | Amblyopia | Vision Screening | Issues | ABCD Clinics | Reference | Contact ABCD