The Hadley School for the Blind

EYE REPORT

To the U.S. student/applicant:
Please mail or take this form to your physician or eye specialist.

To the physician or eye specialist:
Please indicate patient's visual acuity and/or peripheral field and provide the information requested below.

____________________________________________________________________________________________________________
Patient's name

____________________________________________________________________________________________________________
Address

____________________________________________________________________________________________________________
City, State, Zip

1. Does this patient meet the standard definition of legal blindness?

Yes___ No___

2. Condition is considered to be:

Progressive___ Stable___ Capable of improvement___ Uncertain___

3. Diagnosis (each eye):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________
Physician or eye specialist's name

______________________________________________________________________________
Address

______________________________________________________________________________
City, state, zip or postal code

______________________________________________________________________________
Area code and telephone number

RETURN PROMPTLY TO:

The Hadley School for the Blind
Student Services Department
700 Elm Street
Winnetka, IL 60093-0299
Telephone 847-446-8111
Fax 847-446-0855

______________________________________________________________________________
Physician's or eye specialist's signature

______________________________________________________________________________
Date

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