Bioptic Telescopic Lens Vision Examination (Page 2 of 2) in pdf

PATIENT’S NAME ___________________________________________________ DOB ________________

1. Does the patient meet or exceed the minimum acceptable horizontal, binocular field of vision requirements. □ Yes

□ No

NOTE: Field expanders are not allowed to achieve vision requirements.

2. Can applicant recognize and distinguish among traffic control signals and devices showing standard red,

□ Yes

□ No

green and amber colors.

3. What medical conditions caused the present loss of the patient’s visual acuity?

____________________________________________________________________________________________________________

4. Does the patient have any progressive diseases of the eye?

□ Yes

□ No

Cataracts

□ Yes

□ No

Diabetic Retinopathy

□ Yes

□ No

Glaucoma

□ Yes

□ No

Macular Degeneration

□ Yes

□ No

Retinitis Pigmentosa

□ Yes

□ No If so, please describe. ______________________________________

Other

4. How long has this patient been under your care? ________

1. What is the date of the most recent visual examination? ___________________

2. On what date did patient receive telescopic lens? __________________

□ Yes

□ No

3. Did patient complete the prescribed training exercises for the use of the bioptic telescopic lens?

□ Yes

□ No

4. In your opinion, should the patient be restricted to “Daylight Driving Only”?

5. Can you certify that that no ocular diagnosis or prognosis currently exists or is likely to occur during the period of issuance of the

license which would cause deterioration of visual acuity or visual field to levels below the minimum standards. □ Yes

□ No

□ 6 months

□ Yearly

6. Patient should be re-evaluated every :

7. If license issued, what restrictions would be recommended.

□ 5 mile radius of home

□ 10 mile radius

□ 15 mile radius

□ 20 mile radius

□ 25 mile radius

□ No interstate highway

□ light traffic only

Other special restrictions please explain:

____________________________________________________________________________________________________________

________________________________________________________________________

□ Yes □ No

12 In your opinion, would the patient’s condition interfere with the safe operation of a motor vehicle?

If “yes”, please explain in the space provided or attach an explanation on your letterhead.

____________________________________________________________________________________________________________

In accordance with the provisions of R.S. 40:1356, a health care provider is exempt from any liability as a result of reporting to the

Department of Public Safety and Corrections any visual ability, physical condition, impairment or disability which may impair a

person’s ability to exercise ordinary and reasonable control in the operation of a motor vehicle. This form must be completed in its

entirety by an optometrist or ophthalmologist.

Physician’s Signature _________________________________________ Date _______________________

Physician’s Printed Name ______________________________________ Telephone # (___) _____________

Physician’s Address _______________________________________________________________________

Rev. 12/2008

Bioptic Telescopic Lens Vision Examination Page 2

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