Sf-0257 Vision Examination Form (Page 2 of 2) in pdf

Sf-0257 Vision Examination Form Page 2

TENNESSEE DEPARTMENT OF SAFETY

VISION EXAMINATION FORM

1. Are glasses needed for distant vision? ___________________ Are they being prescribed or fitted?________________

2. Describe any irregularities such as : Double vision, poor night vision, eye injury, eye disease, poor near vision, etc:

__________________________________________________________________________________________________

3. Will eye glasses improve conditions described in Question 2 above?_______________________________________

4. Will other treatments improve above-described conditions for the eyes? ____________________________________

__________________________________________________________________________________________________

5. Is the person named in this report currently undergoing the recommend treatment to improve vision? ______________

6. Additional Comments:

__________________________________________________________________________________________________

CERTIFICATION OF OPHTHAMOLOGIST OR OPTOMETRIST

I, _____________________________________________________________, being licensed to practice in the

specialty of eye care, in the State of ___________________________________, certify I have personally

examined the eyes of the above named. A true record of this examination appears on this report and he or she

signed below in my presence.

Signature of Examining Doctor ______________________________________ DATE _________________

Medical License Number ________________________________________

STATE _________________

Office Address ________________________________________________City _________________________

STATE _____________ ZIP CODE _____________Office Telephone Number ________________________

Signature of Person ____________________________________________ DATE _____________________

Receiving Eye Examination

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SF-0257 (Rev. 1/12)

RDA 1348

Sf-0257 Vision Examination Form Page 2