Screening - Oral and Vision/Color

Screening Details

Screening Provider Name

[HealthStudVision]ScreenerName

Date of exam

Screening Date

Date at which screening was done

[HealthStudVision]ScreenDate

Grade

Grade Level

[HealthStudVision]GradeLevelAtScreen

Screening Provider Type

[HealthStudVision]VisionScreenerTypeLuID

Vision and Color

Astigmatism

Astigmatism

Screening for Astigmatism

[S_IL_HSV_X]Astigmatism

Amblyopia

Amblyopia

Screening for Amblyopia

[S_IL_HSV_X]Amblyopia

Pathology

Pathology

Screening for Pathology

[S_IL_HSV_X]Pathology

Combination of Findings

Combination of Findings

Screening for Combination of Findings

[S_IL_HSV_X]Combination of Findings

Others

Others

Screening for Other vision concerns.

[S_IL_HSV_X]Others

Vision Referral Date

[HealthStudVision]ReferralDate

Recommendations -Corrective lenses

Vision Aid

[HealthStudOral]VisionAid

Uncorrected visual acuity - Distance (Right)

Right Eye Vision Test Result

See the Appendix for valid values for the following elements:

HealthStudVisionyeTestLuID

Uncorrected visual acuity - Distance (Left)

Left Eye Vision Test Result

See the Appendix for valid values for the following elements:

[HealthStudVision]LeftEyeTestLuID

Uncorrected visual acuity - Distance (Both)

Both Eyes Test Result

See the Appendix for valid values for the following elements:

[HealthStudVision]bothEyeTestLUID

Best corrected visual acuity - Distance (Right)

Right Eye Result w/ Correction

See the Appendix for valid values for the following elements:

[HealthStudVision]rightEyeTestWithCorrectionLUID

Best corrected visual acuity - Distance (Left)

Left Eye Result w/ Correction

See the Appendix for valid values for the following elements:

[HealthStudVision]leftEyeTestWithCorrectionLUID

Best corrected visual acuity - Distance (Both)

Both Eyes Result w/ Correction

See the Appendix for valid values for the following elements:

[HealthStudVision]bothEyeTestWithCorrectionLUID

Uncorrected visual acuity - Near

Uncorrected visual activity (Near) both

See the Appendix for valid values for the following elements:

[S_IL_HSV_X]Uncorrected_Visual_Activity

Best corrected visual acuity - Near

Best corrected visual activity (Near) both

See the Appendix for valid values for the following elements:

[S_IL_HSV_X]Corrected_Visual_Activity

Was refraction performed with dilation?

Was refraction performed with dilation?

Checkbox

[S_IL_HSV_X]Refraction_Performed

External exam (lids, lashes, cornea, etc.)

External exam (lids, lashes, cornea, etc.)

Dropdown with values - Normal, Abnormal & Not Able to Access

External Exam Comments

[S_IL_HSV_X]External_Exam

[S_IL_HSV_X]External_Exam_Detail

Internal exam (vitreous, lens, fundus, etc.) 

Internal exam (vitreous, lens, fundus, etc.) 

Dropdown with values - Normal, Abnormal & Not Able to Access

Internal Exam Comments

[S_IL_HSV_X]Internal_Exam

[S_IL_HSV_X]Internal_Exam_Detail

Pupillary reflex (pupils) 

Pupillary reflex (pupils) 

Dropdown with values - Normal, Abnormal & Not Able to Access

Pupillary reflex Comments

[S_IL_HSV_X]Pupillary_Reflex

[S_IL_HSV_X]Pupillary_Reflex_Detail

Accomodation and Vergence

Accommodation and Vergence 

Dropdown with values - Normal, Abnormal & Not Able to Access

Accommodation and Vergence Comments

[S_IL_HSV_X]Accomodation_Vergence

[S_IL_HSV_X]Accomodation_Vergence_Detail

Glaucoma evaluation 

Glaucoma evaluation 

Dropdown with values - Normal, Abnormal & Not Able to Access

Glaucoma evaluation Comments

[S_IL_HSV_X]Glaucoma_Evaluation

[S_IL_HSV_X]Glaucoma_Evaluation_Detail

Oculomotor assessment 

Oculomotor assessment 

Dropdown with values - Normal, Abnormal & Not Able to Access

Oculomotor assessment Comments

[S_IL_HSV_X]Oculomotor_Assessment

[S_IL_HSV_X]Oculomotor_Assessment_Detail

Other

Other

Dropdown with values - Normal, Abnormal & Not Able to Access

Details on any other examination taken

[S_IL_HSV_X]Other_Examination

[S_IL_HSV_X]Other_Examination_Detail

Ocular history

Ocular history

Checkbox 

Normal and Positive for details

[S_IL_HSV_X]Ocular_History

[S_IL_HSV_X]Ocular_History_Detail

Medical history

Medical history

Checkbox 

Normal and Positive for details

[S_IL_HSV_X]Medical_History

[S_IL_HSV_X]Medical_History_Detail

Drug allergies

Drug allergies

Checkbox 

Normal and Positive for details

[S_IL_HSV_X]Drug_Allergies

[S_IL_HSV_X]Drug_Allergies_Detail

Other information

Other information

Text Box

[S_IL_HSV_X]Other_Information_Detail

Muscle Balance

See the Appendix for valid values for the following elements:

[HealthStudVision]muscleBalanceLUID

Examination - Color vision

Color Blind Test Result

See the Appendix for valid values for the following elements:

[HealthStudVision]ColorBlindTestLuID

Vision Aid

Text box with details of corrective lenses if recommended

HealthStudVision]VisionAid

Diagnosis

Outcome & Comment

Screening Outcome

See the Appendix for valid values for the following elements:

[HealthScreenLookup]CodeType (Screening element, such as LeftEyeTestCode)

[HealthStudVision]VisionScreenOutcomeLuID

Comment

Recommendation

[HealthStudVision]ScreenComment

Preferential seating recommended

Preferential seating recommended

Checkbox

Textbox - Details

[S_IL_HSV_X]Preferential_Seating

[S_IL_HSV_X]Preferential_Seating_Detail

Corrective lenses

Corrective lenses

Checkbox

Textbox - Details

[S_IL_HSV_X]Corrective_Lenses

[S_IL_HSV_X]Corrective_Lenses_Detail

Recommend re-examination

Recommend re-examination

Dropdown

Textbox - Details

[S_IL_HSV_X]Recommended_Examination

[S_IL_HSV_X]Recommended_Exam_Detail

Screening Details

Date of Most Recent Examination

Screening Date

[HealthStudOral]ScreenDate

Screening Provider Name

[HealthStudOral]ScreenerName

Screening Provider Type

See the Appendix for valid values for this field

[HealthScreenLookup]CodeType (Screening element)

[HealthScreenLookup]CodeType (Screening element)

[HealthStudOral]OralScreenerTypeLuID

Grade Level

Grade

[HealthStudOral]GradeLevelAtScreen

Check Services provided at Examination Date 

Services provided at Screening Date

Checkbox for following (Multiple checkbox can be checked)

Dental Clleaning

Sealant

Flouride Treatment

Restoration of teeth due to Caries

Value stored in each field is 1 or 0

[S_IL_HSO_X]Dental_Cleaning

[S_IL_HSO_X]Sealant

[S_IL_HSO_X]Fluoride_Treatment

[S_IL_HSO_X]Teeth_Restoration

Oral Health Status

Assessment

Dental Sealants Present on Permanent Molars

Dental Sealant Present

Dropdown with value - Yes, No

[HealthStudOral]IsDentalSealantPresent

Malocclusion

Dropdown with value - Yes, No

[HealthStudOral]IsHistoryCariesPresent

Caries Experience / Restoration History

History of  Caries Present

Dropdown with value - Yes, No

[HealthStudOral]IsMalocclusionPresent

Untreated Caries 

Untreated Caries Present

Dropdown with value - Yes, No

[HealthStudOral]IsUntreatedCariesPresent

Urgent Treatment

Treatment Urgency

See the Appendix for valid values for this field

Dropdown with value - Yes, No

[HealthScreenLookup]HealthCategory (user-defined display value)

[HealthStudOral]TreatUrgencyLuID

Outcome & Comments

Screening Outcome

See the Appendix for valid values for this field

[HealthScreenLookup]OralScreeningOutcome

[HealthScreenLookup]OralScreeningOutcome

[HealthStudOral]OralScreenOutcomeLuID

Additional comments

Comments

[HealthStudOral]ScreenComment

Treatment Needs

Treatment Needs

check all that apply. For Head Start Agencies, please also list appointment date or date of most recent treatment completion date.

Restorative Care - Checkbox & Date

Restorative Care - Checkbox & Date

For amalgams, composites, crowns, etc

Checkbox checked if treatment needed

Date to be updated when the treatment is needed

[S_IL_HSO_X]Restorative_Care

[S_IL_HSO_X]Restorative_Appt_Date

Preventive Care - Checkbox & Date

Preventive Care - Checkbox & Date

For sealants, fluoride treatment, prophyl
axis

Checkbox checked if treatment needed

Date to be updated when the treatment is needed

[S_IL_HSO_X]Preventive_Care

[S_IL_HSO_X]Preventive_Appt_Date

 Pediatric Dentist Referral Recommended - Checkbox & Date

 Pediatric Dentist Referral Recommended - Checkbox & Date

Checkbox checked if treatment needed

Date to be updated when the treatment is needed

[S_IL_HSO_X]Pediatric_Dentist_Referral

[S_IL_HSO_X]Treatment_Completion_Date