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    Appendix I: PROFORMA

    Uploaded by

    Vishwas Nayak
    This document contains three appendices related to vision assessment: 1. Appendix I is a proforma used to record a patient's personal details, medical history, vision assessment results, and diagnosis. 2. Appendix II is an informed consent form explaining the risks and benefits of participation in a study on binocular vision dysfunctions and academic performance. 3. Appendix III is a 19-item COVID-19 questionnaire to assess symptoms experienced with near work like reading.

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    © All Rights Reserved
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    Appendix I: PROFORMA

    Uploaded by

    Vishwas Nayak
    43 views6 pages
    This document contains three appendices related to vision assessment: 1. Appendix I is a proforma used to record a patient's personal details, medical history, vision assessment results, and diagnosis. 2. Appendix II is an informed consent form explaining the risks and benefits of participation in a study on binocular vision dysfunctions and academic performance. 3. Appendix III is a 19-item COVID-19 questionnaire to assess symptoms experienced with near work like reading.

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    This document contains three appendices related to vision assessment: 1. Appendix I is a proforma used to record a patient's personal details, medical history, vision assessment results, and diagnosis. 2. Appendix II is an informed consent form explaining the risks and benefits of participation in a study on binocular vision dysfunctions and academic performance. 3. Appendix III is a 19-item COVID-19 questionnaire to assess symptoms experienced with near work like reading.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    43 views6 pages

    Appendix I: PROFORMA

    Uploaded by

    Vishwas Nayak
    This document contains three appendices related to vision assessment: 1. Appendix I is a proforma used to record a patient's personal details, medical history, vision assessment results, and diagnosis. 2. Appendix II is an informed consent form explaining the risks and benefits of participation in a study on binocular vision dysfunctions and academic performance. 3. Appendix III is a 19-item COVID-19 questionnaire to assess symptoms experienced with near work like reading.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 6

    Appendix I: PROFORMA

    S.No.: Date: Time:

    Name: DOB: Sex: Class:

    Academic Score: Family annual income:

    IQ Level with Seguin Form Board: _____sec; IQ=_____

    Ocular History:
    Wearing glasses: Yes/No
    Ocular conditions: Lazy eye/Squint/Cataract/Retinitis Pigmentosa/ any other please
    specify-

    Systemic history: Fever/any systemic inflammation/ Dyslexia/ others please specify-

    Family History of eye problem: if yes please specify

    Current medication:

    Vision assessment:

    Presenting
    Eye visual Objective refraction Subjective refraction MEM
    acuity

    OD

    OS

    33
    Cover Test: Distance:
    Near:

    Ocular health examination:

    Eye Torch Light Examination

    OD

    OS

    Sensory Evaluation:

    Titmus stereopsis Arc sec

    WFDT(Near)

    4Δ BO (Distance)

    OD OS OU
    Amplitude of accommodation
    (Minus Lens Method) D D D
    NPC(Red Green Lens Method)
    cm
    Accommodative Facility
    (+/-2.00D Flipper) cpm cpm cpm
    Vergence Facility
    (3ΔBI/12ΔBO) cpm

    34
    Modified Thorington Test:

    Distance Lateral Phoria - ________Δ

    Near Lateral Phoria - ___________Δ

    With +1.00DS Near Lateral Phoria - ___________ Δ

    Fusional Vergence (Step Vergence):

    Blur Break Recovery

    NFV(Distance)

    PFV(Distance)

    NFV(Near)

    PFV(Near)

    Positive Relative Accommodation: ______________D

    Negative Relative Accommodation: _____________D

    AC/ A ratio (Gradient Method):

    Diagnosis - _____________________________________________

    35
    APPENDIX II: INFORMED CONSENT

    Dear participant,

    This is an observational cross sectional study conducted to see the impact of non-
    strabismic binocular vision dysfunctions on academic performance of primary school
    children. I Namratha, Postgraduate student of department of Optometry , Manipal
    College of Health Sciences,Manipal carrying out this study as a part of my research
    work. I therefore request for your glad participation. As a part of this study I may need
    few personal details and also I will be carrying out a few tests to examine your eyes.

    STATEMENT OF RISK AND BENEFIT: Our testing procedure will be non-invasive.


    We assure you that there is no risk involved in our experiment. There will be no
    monetary or any other compensation for your participation in the study.

    INVESTIGATOR GUARANTEE: The investigators guarantee that no personally


    identifiable data about you will be revealed to anybody. Only average data accumulated
    from many participants like you will be published.

    Date:

    Place: Investigator’s Signature

    PARTICIPANT’S CONSENT

    I have read all the details mentioned above and understood the risks and benefits of the
    experiment. The investigators have orally clarified any doubts I had about my
    participation. I voluntarily accept to participate in the experiment. I understand that there
    will not be monetary or any other compensation given to me for participating in the
    study.

    Date:

    Participant’s Signature
    Place:

    36
    APPENDIX III: COVD-QOL-19 QUESTIONNAIRE
    Name: Class:

    Never Seldom Occasional Frequently Always

    1 Headaches with near work

    2 Words run together reading

    3 Burn, itchy, watery eyes

    4 Skips/repeats while reading

    5 Head tilt/close one eye when reading

    6 Difficulty copying from chalkboard

    7 Avoids near work/reading

    8 Omits small words when reading

    9 Writes up/down hill

    10 Misaligns digits/columns of numbers

    11 Reading comprehension down

    12 Holds reading too close

    13 Trouble keeping attention on reading

    14 Difficulty completing assignments on


    time
    15 Always says ‘I can’t’ before trying

    16 Clumsy, knocks things over

    17 Does not use his/her time well

    18 Loses belongings/things

    19 Forgetful/poor memory

    37
    38

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