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qg_C5

Label

C5

Question Text

Test at exactly 20 feet with a standard Snellen Chart of block capitals. Hang chart in good light level with teenager's eyes and free from glare. Occlude opposite eye in usual way. Test all teenagers (without glasses) first and record result separately for Right Eye and Left Eye. Then re-test only teenagers with glasses/lens, wearing them.

DISTANT VISUAL ACUITY

1 - 6

2 - 9

3 - 12

4 - 18

5 - 24

6 - 36

7 - 60

8 - Worse than 60

9 - Unable to test

Crude distant vision without glasses (test all teenagers): Right eye
Crude distant vision without glasses (test all teenagers): Left eye
Distant vision, wearing glasses/contacts: Right eye
Distant vision, wearing glasses/contacts: Left eye

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If YES to any of above, please describe

Long text
Test at exactly 20 feet with a standard Snellen Chart of block capitals. Hang chart in good light level with teenager's eyes and free from glare. Occlude opposite eye in usual way. Test all teenagers (without glasses) first and record result separately for Right Eye and Left Eye. Then re-test only teenagers with glasses/lens, wearing them.
DISTANT VISUAL ACUITY

1 - 6

2 - 9

3 - 12

4 - 18

5 - 24

6 - 36

7 - 60

8 - Worse than 60

9 - Unable to test

Crude distant vision without glasses (test all teenagers): Right eye
Crude distant vision without glasses (test all teenagers): Left eye
Distant vision, wearing glasses/contacts: Right eye
Distant vision, wearing glasses/contacts: Left eye
A Sheridan-Gardiner near-vision chart is provided in the instruction manual. The teenager should hold it in a good light at a distance of approximately 10 inches away from the eyes. Please occlude the other eye efficiently without pressure on the eyeball. If the teenager cannot read, ask him/her to draw the letters in the air. Test near vision in all teenagers and then retest only teenagers with glasses/lenses, wearing them.
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1 - 6

2 - 9

3 - 12

4 - 18

5 - 24

6 - 36

7 - 60

8 - Worse than 60

9 - Unable to test

Near Vision without glasses (all teenagers): Right eye
Near Vision without glasses (all teenagers): Left eye
Near Vision wearing glasses/contacts: Right eye
Near Vision wearing glasses/contacts: Left eye
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