3-year-old Children
Lea 5' Visual Acuity Recording Form
1. Name: ___________________________________ Age:______
2. Screener: ________________________________
3. Check unable box if child cannot complete Lea Pretest: Unable
1
STOP!
Baseline Flip Book Right Eye
0 or 1 X
✔
check here if child
correctly identified all cards
presented with right eye
3R 1
3R 2
3R 3
3R 4
3R 5
3R 6
3R 7
3R 8
3L 1
3L 2
3L 3
3L 4
3L 5
3L 6
3L 7
3L 8
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Phone: 800-362-3860 Fax: 888-362-2576
www.good-lite.com
GOOD-LITE
The Quality Always Shines Through
Produced exclusively by:
As used in the Vision In Preschoolers (VIP) Study (sponsored
by the National Eye Institute of the National Institutes of Health
of the Department of Health and Human Services)
2 or more X’s
3R 5
3R 6
3R 7
3R 8
Right Eye Disk
If 2 or
more X’s
STOP
If 2 or
more X’s
STOP
4.
Right Eye Disk
Start at 3R1
Right Eye Disk
3R 1
3R 2
3R 3
3R 4
Right Eye Disk
Baseline Flip Book Left Eye
0 or 1 X
2 or more X’s
Left Eye Disk
If 2 or
more X’s
STOP
If 2 or
more X’s
STOP
5.
Left Eye Disk
Start at 3L1
Left Eye Disk
Left Eye Disk
3L 1
3L 2
3L 3
3L 4
3L 5
3L 6
3L 7
3L 8
6.
PASS
REFER
✔
check here if child
correctly identified all cards
presented with left eye
