OPHTHALMOLOGICAL EVALUATION
Applicant's Name
First Name
Middle Name
Last Name
Rows
Right Eye
Left Eye
Uncorrected Vision
Best Corrected Visual Acuity
Is there any evidence of ocular disease that would be chronic, progressive, or require frequent treatment or surgery?
Yes
No
If Yes, please explain:
Is there any limitation of vision that would preclude the applicant's performance of college level near tasks?
Yes
No
If Yes, please explain:
Signature of Ophthalmologist or Optometrist
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