Form Dl 62 - Report Of Vision Exam
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2962
REPORT OF VISION EXAMINATION
A Public Service Agency
APPLICANT COMPLETES THIS SECTION
INSTRUCTIONS: Please complete the driver license number, date of birth, telephone number, name, and address areas
of this form. You must sign and date the authorization line. All medical information received by the Department of Motor
Vehicles (DMV) is confi dential under California Vehicle Code (CVC) Section 1808.5. Please bring this completed form and
any new corrective lenses with you when you return to DMV for further testing. If any section of this form is incomplete, it may
have to be returned to the vision specialist for completion. DO NOT MAIL THIS FORM BACK TO DMV unless asked to do
so by a DMV employee. Alterations or erased information may void this form.
Your vision specialist should conduct a new vision examination unless one has been conducted within the last six months.
DMV will make the fi nal licensing decision based on a combination of factors, including information from your vision
specialist.
DRIVER LICENSE NUMBER
DATE OF BIRTH (MO., DAY, YR.)
HOME TELEPHONE NUMBER
NAME (FIRST, MIDDLE, LAST)
RESIDENCE ADDRESS
CITY
STATE
ZIP CODE
I authorize the vision specialist conducting this examination to provide the Department of Motor Vehicles with the following
information for its confi dential use (CVC §1808.5) in evaluating my ability to safely operate a motor vehicle.
APPLICANT’S SIGNATURE
DATE
• 20/40 with both eyes tested together, and
• 20/40 in one eye, and
DMV’s Visual Acuity Screening Standard is:
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• 20/70, at least, in the other eye.
OPHTHALMOLOGIST OR OPTOMETRIST COMPLETES THOSE SECTIONS THAT APPLY —
Information must be from exam
within last 6 months.
1. REFRACTION — Complete only those sections that apply.
HAVE NEW DISTANCE LENSES BEEN PRESCRIBED AND FITTED?
DATE NEW LENSES WERE PRESCRIBED
IS NIGHT DRIVING RECOMMENDED?
Yes
No
If yes:
Glasses
Contact Lenses
Yes
No
IS MONOVISION EMPLOYED?
DID YOUR PATIENT RECEIVE BIOPTIC LENS TRAINING?
By contact lenses
Yes
No
Yes
No
Not Known
By refractive surgery
Yes
No
DID PATIENT RECEIVE BIOPTIC LENS TRAINING THAT INCLUDED DRIVING?
Is best corrected visual acuity in each eye recommended for driving?
Yes
No
Yes
No
Not Known
SKILL IN USING BIOPTIC TELESCOPE
Bioptic Telescope
Right eye 20/ ___________
Left eye 20/___________
Satisfactory
Unsatisfactory
Not Known
Bioptic Telescope suitable for driving?
Yes
No
2. VISUAL ACUITY — Complete Clinical Measurement Section. Lenses include contact lenses or glasses.
DMV MEASUREMENT (FOR DMV USE ONLY)
CLINICAL MEASUREMENT (WITHOUT BIOPTIC TELESCOPE)
Both Eyes
Right Eye
Left Eye
Both Eyes
Right Eye
Left Eye
Without Lenses
20/
20/
20/
Without Lenses
20/
20/
20/
With Current Lenses
20/
20/
20/
With Lenses
20/
20/
20/
Best Corrected Visual Acuity 20/
20/
20/
3. DIAGNOSIS —
Please indicate vision condition by checking the box(es) representing affected eye(s). If the diagnosed condition is not listed, write the
diagnosis under “other diagnosis/comments” below.
REFRACTIVE R L
DEVELOPMENTAL
R L
OPTICAL
R L
RETINAL/OPTIC NERVE R L
VISUAL FIELDS
R L
Astigmatism
Amblyopia
Cataract
Diabetic Retinopathy
Decreased Peripheral Vision
Hyperopia
Strabismus
Corneal Opacity
Macular Degeneration
Hemianopia
Myopia
Congenital Nystagmus
Diplopia (uncorrectable)
Glaucoma
Quadrantanopia
Albinism
Keratoconus
Retinal Detachment
Decreased Peripheral Vision. Please
Aphakia
Retinitis Pigmentosa
identify the areas affected on the chart in
Section 5 (see reverse).
Pseudophakia
Retinal Damage
Post. Caps. Opac.
(CRVO, PRP etc.)
Other diagnosis/comments _______________________________________________________________________________________________
_____________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________
Monocular Vision (No Light Perception or Prosthesis) If monocular, when was the monocular vision diagnosed? ___________________________
If monocular, does the patient have a medical condition that could affect the functional eye in the future?
Yes
No
Any eye surgery (including refractive)?
Yes
No Date of most recent surgery ____________ Type of surgery_____________________
DL 62 (REV. 4/2007)
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