Box 1
Functional vision checklist.
a. Pupillary reaction:
_present
_absent
_R
_L
b. Muscle imbalance:
_present
_absent
_R
_L
c. Blink reflex:
_present
_absent
_R
_L
d. Visual field loss:
_present
_absent
_R
_L
e. Peripheral field loss:
_present
_absent
_R
_L
f. Visual field preference:
_present
_absent
_R
_L
g. Eye preference:
_present
_absent
_R
_L
a. Inappropriate visual behaviors:
_present
_absent
b. Tracking ability:
_present
_absent
_light
_objects
_vertical
_circular
_horizontal
_oblique
c. Reaches for toys:
_present
_absent
_in front of him
_to his right
_to his left
_above eye level
_below eye level
d. Shifts attention:
_present
_absent
_both sides
_one side
_R
_L
e. Scanning ability:
_present
_absent
a. Locates dropped toy:
_present
_absent
_distance
_peg or candy
_inch cubed blocks
_shape chips
b. Small toy observed:
_present
_absent
_distance
c. Large toy observed:
_present
_absent
_distance
d. Objects matched:
_present
_absent
_distance
_large toys distance
_small toys distance
a. Visual pursuit:
_present
_absent
b. Causality:
_present
_absent
c. Object permanence:
_present
_absent
d. Object concept:
_present
_absent
e. Means-ends:
_present
_absent
a. Approach:
1. pegs:
_visual
_tactual
_O
_U
2. stacking cone:
_visual
_tactual
_O
_U
3. puzzles:
_visual
_tactual
_O
_U
4. pounding bench:
_visual
_tactual
_O
_U
5. beads:
_visual
_tactual
_O
_U
b. Matching:
1. colored blocks:
_matches
_does not match
_near distance
_far distance
2. shapes:
_matches
_does not match
_near distance
_far distance
3. pictures:
_matches
_does not match
_near distance
_far distance
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