Form Dl 62 - Report Of Vision Exam Page 2
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2962
DRIVER LICENSE NUMBER: ____________________________
4. PROGNOSIS
Diagnosis ______________________________________
Static
Progressive
Stable since _______________ (date)
Diagnosis ______________________________________
Static
Progressive
Stable since _______________ (date)
Diagnosis ______________________________________
Static
Progressive
Stable since _______________ (date)
WHEN SHOULD DMV REQUIRE A NEW DMV VISION EXAMINATION REPORT FORM BE SUBMITTED?
Not applicable
1 year
2 years
5 years
Other ___________________________________________________________________
5. VISUAL FIELDS —
If vision is not correctable to 20/40 in each eye, or there is possible visual fi eld loss, a full visual fi eld examination (confrontation
is permissible) must be performed. Show the approximate peripheral extent and any scotomas in the diagram below.
RIGHT EYE
LEFT EYE
Extent:
Extent:
__________________
Left
Left
__________________
__________________
Right
Right __________________
__________________
Up
Up
__________________
__________________
Down
Down __________________
6. VISUAL ABNORMALITIES — The following information will help our examiners evaluate your patient’s ability to safely operate a motor
vehicle. Based upon your testing, clinical impression, or knowledge of the disorder, please indicate the severity of any of the following
visual abnormalities which your patient may be experiencing. Indicate severity of condition by placing a 1 (mild), 2 (moderate), or
3 (severe) in the box(es) below.
R L
R L
R L
R L
R L
Decreased Acuity
Visual Field Loss
Contrast Sensitivity Loss
Problems With Glare
Poor Night Vision
Color Defect
Reduced Depth Perception
Abnormal Eye Movements
7. ADVICE —
Have you given your patient any advice about driving?
Yes
No
If yes, please explain in #8 below.
8. ADDITIONAL COMMENTS — Report any additional information or comments you feel DMV should know concerning your
patient’s visual and perceptual capabilities relating to driving performance. You may use an additional sheet of paper to provide this
information as well as information about any existing conditions which contribute to poor night vision or poor depth perception, etc.
Any recommendations about the patient’s general safety should also be made. DMV will make the fi nal licensing decision based
on a combination of factors, including your professional expertise.
9. SIGNATURE — This section must be completed to validate this report.
PRINTED NAME
M.D. OR O.D. LICENSE NUMBER
SIGNATURE
DATE OF EXAM
(MUST BE WITHIN LAST 6 MONTHS)
X
ADDRESS
CITY
ZIP CODE
TELEPHONE NUMBER
(
)
DL 62 (REV. 4/2007)
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