Eye Evaluation Mvd
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1Eye Evaluation
P.O. Box 201430, Helena, MT 59620-1430 Phone (406) 444-3933 Fax (406) 444-1631
DriverLicense@mt.gov
Please PRINT
Legal Last Name
Legal First Name
Driver License Number
Mailing Address
City
State
Zip
Date of Birth
Email Address
Phone Number
Explanation for Eye Specialist
The Motor Vehicle Division requires information to verify a driver meets Montana vision standards for the purpose of driver license issuance. This
form must be completed by an eye specialist. The eye specialist assumes no responsibility in making this report other than that of precisely
representing the facts.
Please complete this form for the examination you conduct. Attach a separate sheet if the case is unique and additional comments are
necessary. For proper identification, have the driver sign the report in your presence.
RELEASE OF INFORMATION BY DRIVER – SIGN IN PRESENCE OF EYE SPECIALIST
I authorize my eye specialist to answer any questions from the Motor Vehicle Division or its employees relating to my physical or medical
condition and to release any related information or records to the Motor Vehicle Division or its employees. Any expense involved is to be
charged to me and not the State of Montana.
I authorize the Motor Vehicle Division to receive any information relating to my physical or medical condition and to use the same in determining
whether I have the ability to safely operate a motor vehicle.
Signed:
Date:
Distant
Right Eye
Left Eye
Both Eyes
BREADTH OF VISION FIELD
Vision Only
Only
Only
Together
With Present
20/
20/
20/
To Right of
To Left of Point
Glasses
Point of Fixation
of Fixation
Without
20/
20/
20/
Glasses
Best Possible
20/
20/
20/
Total Angle
__________________________
Correction
Type of instrument used to determine visual acuity:
System
Snellen Chart
Are you fitting glasses for distant vision?
Yes
No
Is there double vision?
If yes, describe:
Yes
No
Can the double vision be corrected with glasses:
Yes
No
N/A
Other treatment?
Yes
No
N/A
Are you undertaking such correction or treatment?
Yes
No
N/A
Is there any evidence of eye disease or injury resulting in vision impairment?
Yes
No If yes, describe:
Is there any unusual difficulty seeing at night?
Yes
No If yes, explain:
Is the patient color blind?
Yes
No If yes, explain:
Do you recommend a drive test?
Yes
No Do you recommend a medical evaluation?
Yes
No
Is your patient visually capable of operating a motor vehicle?
Yes
No
If no, describe:
Recommended license restrictions:
None
Corrective Lenses
No inclement weather
No night driving
Do you recommend submission of a periodic Eye Evaluation (form 22-1801) to the MVD by your patient to monitor changes?
Yes
No
If yes, how often do you recommend your patient submit form 22-1801?
6 months
1 year
2 years
____ years
Certification of Eye Specialist
Print Name:
Type of Practice or Medical Specialty:
Medical License Number:
Address:
Email:
Phone Number:
Signature:
Date:
22-1801 (3/17)
Montana state authorities reserve the right to reject any form that has been altered. This form is available in alternate formats for people with disabilities.
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