Vision
EYE DOMINANCE
Child holds tube ____ teacher holds tube ____ flashlight used ____
First trial: Right ____ Left ____
Second trial: Right ____ Left ____
Third trial: Right ____ Left ____
EYE CONTACT
Maintains ____ momentary ____
Eye contact at several feet ____
Eye contact within one foot ____
Eye contact if turn child’s head toward examiner ____
Eyes avert direct eye contact ____
RESPONSE TO NATURAL LIGHT
Child seeks shaded areas ____
Child creates shaded areas ____
Child moves to source of light ____
Child turns head to source of light ____
Child moves away from source of light ____
Child turns head from source of light ____
RESPONSE TO ARTICIAL LIGHT – flashlight pursuit
Observe: blinking, head movements, eye jerkiness, ability to locate, light-gazing, etc.
Description:
IMPROVING VISUAL FUNCTIONING
Moves material close to eyes ____
Moves head close to the materials ____
Closes one eye ____
Moves eyes to left ____
Moves eyes to right ____
Squints ____
Contorts face ____
GLASSES
Accepts glasses ____
Looks over top of glasses ____
Adjust glasses ____
Removes glasses ____
HEAD POSITION
Child improves visual function by:
Tilting head to left ____
Tilting head to right ____
Tilting head up ____
Tilting head down ____
Shakes head ____
No head adjustment ____
SCANNING
Child scans objects across room ____
Child scans objects within 8-10 feet ____
Child scans objects on table ____
Does not visually explore environment ____
- TRACKING OBJECT
Dangling ring ____ plastic ring ____ ring and light ____
Pursues ring with good fixation for 180 degrees (20 wks) ____
Follows 180 degree arc with blinking or jerking eye movement (12 wks)____
Prompt midline regard (12 wks) ____
Delayed midline regard (8 wks) ____
Follows to midline – other eye takes over (0-4 wks) ____
Moves head ____
Regards when brought in line of vision only (0-4 wks) ____
DETECTING SMALL MOVING OBJECTS
Jumping bean (0-4 wks) ____ red ball (0-4 wks) ____ wind-up toy (0-4 wks) ____
Child can detect small moving object ____
At 10 feet ____
At 5 feet ____
At arm’s length ____
At less than one foot ____
Cannot detect ____
DETECTING SMALL STATIONARY OBJECTS
Raisin ____ bead ____
Child can detect small stationary objects ____
At 10 feet ____
At 5 feet ____
At arm’s length ____
At less than one foot ____
Cannot detect ____
DETECTING LARGE MOVING OBJECTS
Child can detect large moving objects ____
At 10 feet ____
At 5 feet ____
At arm’s length ____
At less than one foot ____
Cannot detect ____
DETECTING LARGE STATIONARY OBJECTS
Child can detect large stationary objects ____
At 10 feet ____
At 5 feet ____
At arm’s length ____
COLOR AGAINST COLOR BACKGROUND
Large object ____small ____buttons ____ raisins and marshmallows ____
Black on black ____
White on white ____
White on black ____
Red on red ____
Blue on blue ____
Yellow on yellow ____
FIGURE-GROUND
Number(s) of plate (s) used ____
Sock ____ car ____ spoon ____ chair ____
VISUAL CLOSURE
Number of templates used____
Apple ____ bed ____sneakers ____sink ____ pants ____
