{"content":[{"text":"HB 95 Eye Examination Report","bbox":{"left":0.375651,"top":0.045741,"width":0.24829799999999996,"height":0.016778999999999995}},{"text":"Name of student ___________________________________________DOB ______ Age ______ \n Grade__________ School ________________________________________________________ \n Parent Name _____________________________________ Date of exam __________________","bbox":{"left":0.058627,"top":0.082407,"width":0.762493,"height":0.05162799999999999}},{"text":"Please complete every blank of this form!","bbox":{"left":0.33263,"top":0.146347,"width":0.334352,"height":0.01677899999999999}},{"text":"Visual Acuity (mark all that apply) \n Distance \n Without Rx: (R) 20/______ \n With old Rx: (R) 20/______","bbox":{"left":0.058627,"top":0.175438,"width":0.29138800000000004,"height":0.06889999999999999}},{"text":"Near \n (R) 20/______ \n (R) 20/______","bbox":{"left":0.529216,"top":0.19271,"width":0.11491699999999994,"height":0.05162800000000001}},{"text":"(L) 20/_____ \n (L) 20/_____","bbox":{"left":0.382157,"top":0.210286,"width":0.104012,"height":0.034052}},{"text":"(L) 20/_____ \n (L) 20/_____","bbox":{"left":0.676274,"top":0.210286,"width":0.10401199999999988,"height":0.034052}},{"text":"Old Rx","bbox":{"left":0.058627,"top":0.262407,"width":0.060471,"height":0.01677899999999999}},{"text":"OD: \n OS:","bbox":{"left":0.176274,"top":0.262407,"width":0.03376899999999999,"height":0.03435499999999997}},{"text":"No Rx ⁪1","bbox":{"left":0.705686,"top":0.262407,"width":0.07782699999999998,"height":0.01748299999999997}},{"text":"Cover Test \n Distance: \n Near:","bbox":{"left":0.058627,"top":0.314832,"width":0.103456,"height":0.05162699999999998}},{"text":"Correction worn (check one)","bbox":{"left":0.411568,"top":0.314832,"width":0.23573499999999997,"height":0.01677899999999999}},{"text":"No Rx ⁪1 \n Old Rx ⁪2 \n New Rx ⁪3","bbox":{"left":0.688264,"top":0.314832,"width":0.09088699999999994,"height":0.052331000000000016}},{"text":"Color Perception (males only)","bbox":{"left":0.058627,"top":0.384529,"width":0.24556699999999998,"height":0.01677899999999999}},{"text":"Normal ⁪1 \n Deficient ⁪2","bbox":{"left":0.680117,"top":0.384529,"width":0.09903400000000007,"height":0.03475499999999998}},{"text":"Refraction \n OD: \n OS:","bbox":{"left":0.058627,"top":0.43665,"width":0.08928499999999999,"height":0.05162699999999998}},{"text":"(check one) Cycloplegic ⁪1 \n Non-cycloplegic ⁪2","bbox":{"left":0.529216,"top":0.43665,"width":0.249934,"height":0.03505900000000006}},{"text":"20/_____ \n 20/_____","bbox":{"left":0.396317,"top":0.454226,"width":0.07407400000000003,"height":0.03405099999999994}},{"text":"Final Prescription \n OD: \n OS: \n Add:","bbox":{"left":0.058627,"top":0.506347,"width":0.151937,"height":0.06920300000000001}},{"text":"Diagnoses (mark all that apply) \n ⁪1 Amblyopia \n ⁪2 Strabismus \n ⁪3 Convergence problems \n ⁪4 Accommodation problems \n ⁪5 Ocular health: \n ⁪6 Other: \n ⁪7 Other: \n ⁪8 Other:","bbox":{"left":0.058627,"top":0.593619,"width":0.296792,"height":0.15687700000000004}},{"text":"Exam was paid by \n ⁪1 Private Pay \n ⁪2 Medical Insurance \n ⁪3 Vision Insurance \n ⁪4 Lions Club \n ⁪5 Free Exam by Doctor \n ⁪6 Other:","bbox":{"left":0.058627,"top":0.767862,"width":0.25756900000000005,"height":0.12202800000000003}},{"text":"Retain copy in patients file","bbox":{"left":0.394708,"top":0.937256,"width":0.21018199999999992,"height":0.01677899999999999}}],"images_bbox":[],"images_bbox_not_text_overlap":[]}