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Visual Impairment 2312 - Oregon

Visual Impairment Form. This is a Oregon form and can be used in Medical Workers Comp .
 Fillable pdf Last Modified 6/30/2010
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Visual Impairment Workers name: Date of injury: Visual acuity: Report the central visual acuity for each eye, distance and near vision, through best correction recommended by the workers physician. L.E. R.E. Distance vision, reported in standard increments of Snellen notation / / If distance vision is less than 20/400, can the worker count fingers at four feet? yes no yes no Near vision, reported in Snellen 14/14 notation. Revised Jaeger or American point type units Natural lens yes no yes no Implanted prosthetic lens yes no yes no Aphakia yes no yes no Visual field deficits: N/A Measure each visual field using a Goldmann perimeter with a lll / 4e stimulus. Report the results on either: 1. A perimetric chart which indicates the extent of retained vision out to 90 for each of the eight standard 45 meridians, as reproduced to the right, or 2. a monocular Esterman grid. Ocular motility: N/A Report binocular diplopia in degrees along the eight standard meridians, as reproduced to the left. Impairments of lacrimal system: N/A If too little or too much tearing restricts the worker from Additional ocular disturbances N/A any part of regular work, specify the affected eye and Indicate the affected eye: whether the condition : Mild Moderate Severe is a nuisance but does not prevent most regular Glare problems work activities Monocular diplopia prevents some regular work-related activities prevents most regular work-related activities Examining physician name & title (print or type): Signature: Date of examination: 440-2312 (9/97/DCBS/WCD/WEB)
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