Form Dl-122 - Diabetic Form Page 2

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DL-122 (4-12)

Patient Name ___________________________________________ Driver's License Number_________________________

REGULAR DRIVER (CLASS A, B, C & M)

UNCORRECTED

R 20/

1. Please indicate individual's visual acuity by marking the appropriate box:

20/

❑

A. Combined vision is 20/40 or better. . . .With Correction

W/O Correction

B 20/

CORRECTED

❑

B. Combined vision is poorer than 20/40 but has been corrected to 20/60 or better.

R 20/

20/

❑

C. Combined vision is poorer than 20/60 but has been corrected to at least 20/70.

B 20/

❑

a) Do you consider this person visually capable to drive?. . . . Yes

❑

D. Combined vision is poorer than 20/70 and not correctable to 20/70.

CHECK ONE: YES NO

2. Is individual's combined field of vision at least 120° in the horizontal meridian,

❏ ❏

excepting the normal blind spots? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

❏ ❏

3. Does individual have better than 20/100 vision in each eye with correction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

❏ ❏

4. Must individual wear corrective lenses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

❏ ❏

5. Does this individual no longer require corrective lenses as a result of corrective surgery? . . . . . . . . . . . . . . . . . . .

❏ ❏

6. Is correction obtained through telescopic lenses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

❏ ❏

7. Did this individual have a dilated eye exam? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Date of last dilated eye exam: _______________________________

HEALTH CARE PROVIDER INFORMATION (Please print or type)

HEALTH CARE PROVIDER'S NAME

SPECIALTY

HEALTH CARE PROVIDER'S LICENSE NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

FAX NUMBER

I hereby state that the facts above set forth are true and correct to the best of my knowledge, information and belief. I understand that the statements made herein

are made subject to the penalties of 18 Pa. C. S. §4904 (relating to unsworn falsification to authorities). Punishable by a fine up to $2,500 and/or imprisonment

up to 1 year.

Health Care Provider's Signature

Date

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