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MTO Vision Report Assessment Form

The document is an assessment form for visual impairments used by the Ministry of Health in Kenya. It includes sections for personal information, medical history, ocular history, visual acuity tests, and specialized tests, along with a conclusion regarding the cause and category of vision impairment. The form must be verified by the County Director of Health and requires signatures from the assembled medical team.

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emmanuel nyongesa
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168 views3 pages

MTO Vision Report Assessment Form

The document is an assessment form for visual impairments used by the Ministry of Health in Kenya. It includes sections for personal information, medical history, ocular history, visual acuity tests, and specialized tests, along with a conclusion regarding the cause and category of vision impairment. The form must be verified by the County Director of Health and requires signatures from the assembled medical team.

Uploaded by

emmanuel nyongesa
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

REPUBLIC OF KENYA

MINISTRY OF HEALTH
Ref: MOH/276B
ASSESSMENT FORM FOR VISUAL IMPAIRMENTS
Date: DD MM YYYY
Name of Health Facility:

Applicant Information for the purpose of reporting on Disability Assessment:

Name: ID No. Gender:

Date of DD / MM / YYYY
Birth:
Occupation: Phone No.
Age:

Sub-
County: Marital Status:
County:

Next of Kin Details:

Name: Relation: Phone No.

Assembled Medical Team details:

SIGNATURE Health Facility


MEMBERS NAME REG. NO.
Official Stamp
Chairperson

Member

Member

Member

(I understand that giving false information is punishable by the laws of Kenya)


Note: the committee should have a minimum of three Members
HISTORY

ASSISTIVE DEVICE

……………………………………………………………………………………………………………………………………………………………
……………….……………………………………………………………………………………..

MEDICAL HISTORY

……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………

OCULAR HISTORY

……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………………………
…………………………………………………

Distance Visual Without


With Correction Correction
Acuity

Right Eye

Left Eye

Near Vision Test

Ophthalmic Examination

Examination Right Left Eye Right Eye Left Eye


Eye

Present
eyeball Cornea

Squint Anterior Chamber

Nystagmus Iris

Tearing Pupil

Lids Lens

Conjunctiva Fundus
Specialized Tests

Test Findings/Defect

Humphreys Visual
Field

Colour Vision

Stereopsis

Conclusion

Cause of Vision
Category Tick Impairment

Normal

Percentage
Mild Impairment Disability

Moderate
Impairment

Any Possible
Severe Impairment Intervention Yes

Blind No

Near Vision
Impairment Recommendation

TEMPORARY PERMANENT

VERIFIED BY THE COUNTY DIRECTOR OF HEALTH


COUNTY DIRECTOR OF
Name.................................................................... HEALTH OFFICIAL STAMP

Date .......................................................................

Signature....................................................................

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