Visual Impairment Worker's name: DOI: WCD #: Note: All visual loss is measured with best correction, using the lenses recommended by the worker's physician. Visual acuity: Report the central visual acuity for each eye, distance and near vision. 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? Near vision, reported in Snellen 14/14 notation. Revised Jaeger or American point type units Natural lens Implanted prosthetic lens Aphakia L.E. / yes no yes yes yes no no no R.E. / yes no yes yes yes no no 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 degrees for each of the eight standard 45-degree meridians, as reproduced above, or 2. a monocular Esterman grid Impairments of lacrimal system: N/A If too little or too much tearing restricts the worker from any part of regular work, specify the affected eye and whether the condition: is a nuisance but does not prevent most regular work activities prevents some regular work-related activities prevents most regular work-related activities Examining physician name and title (print or type): Signature: 440-2312 (5/13/DCBS/WCD/WEB) Ocular motility: N/A Report binocular diplopia in degrees along the eight standard meridians, as reproduced above. Additional ocular disturbances N/A Indicate the affected eye: Mild Moderate Glare (photophobia) Monocular diplopia Stereopsis Severe Date of examination: American LegalNet, Inc. www.FormsWorkFlow.com