Form 32-4001 - Vision Examination Report
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2Mail Drop 818Z
VISION EXAMINATION REPORT
Medical Review Program
Motor Vehicle Division
PO Box 2100
Please read instructions on reverse before completing.
Phoenix AZ 85001-2100
32-4001 R10/08
Clear
Driver Name (first, middle, last, suffix)
Date of Birth
Driver License Number
State Phone
(
)
Street Address
City
State Zip
Vision Symptoms Reported (MVD Use Only)
MUST BE COMPLETED BY PATIENT
Medical Information Release – I hereby authorize this physician to release to the Motor Vehicle Division any requested medical information that
is pertinent to my ability to safely operate a motor vehicle.
Patient Name (or legal guardian)
Signature
Date
MUST BE COMPLETED BY PHYSICIAN –
Examination Date must be within 90 days of the date received by MVD to be accepted
.
Examination Date
Diagnosis
Bioptic Telescopic Lens System
Uncorrected
R:
L:
Both:
Visual Acuity
Yes
No Meets minimum MVD vision standards
Corrected
R:
L:
Both:
Yes
No Magnification is 4X or less
Temporal
R:
L:
Visual Field
Yes
No Eye disease is progressive
(include specific parameters)
Nasal
R:
L:
Does this person have monocular vision?
Yes
No
Do you recommend that MVD monitor this person’s condition by requiring periodic vision reports?
Yes (please explain)
No
MVD vision standards specify that persons with diagnosed impaired night vision be restricted to daytime driving only. Do you recommend the
restriction for this person? Authority: R17-4-503
Yes
No
Any recommendations on this person’s ability to safely operate a motor vehicle?
Yes (please explain)
No
Recommendations
Physician or Optometrist Name (printed)
Physician or Optometrist Signature
Medical License Number
State
Phone
MD
DO
OD
(
)
Street Address
City
State Zip
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