Di-4v Vision Specialist Statement Of Examination Form Page 2
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4SECTION 2: QUESTIONS FOR DRIVERS
Failure to truthfully and completely respond to all questions may result in withdrawal of driving privileges.
1. Do you have difficulty with daylight driving or reading road signs?
Yes
No
2. Do you have difficulty seeing at night?
Yes
No
3. Do headlights from other vehicles significantly interfere with your vision at night?
Yes
No
4. Has any family member, friend, physician or police officer made a suggestion that you not drive
or limit your driving?
Yes
No
5. How many accidents have you had while driving in the past 5 years? ________________
None
6. Please list all prescribed medications you are currently taking:
None
___________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
7. Do you require a passenger to assist you when driving?
Yes
No
8. Were you advised to obtain glasses?
Yes
No
9. When was your last eye exam? ________________________________
Were you given a prescription for new corrective lenses?
Yes
No
If yes, when did you receive them? _________________________________
From whom did you receive them (name, address, and telephone number)? ___________________________
_________________________________________________________________________________________
10. Do you use a special adaptive device while driving such as a bioptic telescopic lens?
Yes
No
If yes, please answer the following questions:
What device do you use? ____________________________________________________________________
How long have you used it for driving? _________________________
Have you received any training to use it?
Yes
No
If yes, when? _________________________________
From whom did you receive training (name, address, and telephone number)? __________________________
________________________________________________________________________________________
DI-4V (2-13)
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