North Carolina Department Of Motor Vehicles Vision Specialist Form Dl77

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North Carolina Department of Motor Vehicles Vision Specialist Form DL77
(rev 6/29/2015)
I, _____________________________________________, hereby authorize Dr. _______________________________to provide my
examination information for the purposes of determining my visual fitness to operate a motor vehicle. I understand this authorizes
the Division’s panel of physicians to review my case.
Applicant Signature___________________________________________ License/Customer number___________________________
Parent/Guardian if Minor______________________________________ Telephone number_________________________________
To be completed by licensed Ophthalmologist or Optometrist
1. What is the vision diagnosis?____________________________________________________________________________
☐ right
☐ left
☐ both
2. Which eye(s) are affected:
☐ permanent
☐ stable
☐ worsening
☐ improving
3. Is the condition:
4. Best corrected Visual Acuity:
Both 20/
Right 20/
Left 20/
(Using conventional lenses)
5. Uncorrected Visual Acuity:
Both 20/
Right 20/
Left 20/
☐ Yes
☐ No
6. New lenses prescribed?
6
☐ Yes
☐ No
7. Are corrective lenses recommended for driving?
8. What is the horizontal field of view in each eye without field expanders? (Specify in degrees)
Right Eye:
______ ° nasal
_____ ° temporal Left
Left Eye:
_______ ° nasal
______ ° temporal
6.
Test used: ☐ Confrontation
☐ Goldmann
☐ Automated
9. Are there other visual issues that might affect driving?
6
☐ No ☐ Depth perception ☐Diplopia
☐Contrast sensitivity
☐Glare sensitivity ☐Other:____________________
☐ Yes
☐ No (If no, skip to # 16)
10. Is a bioptic telescope used for driving?
☐ New
11. If yes, how long has the bioptic been used?
Duration: _______months/years (circle)
☐ Right
☐ Left
☐ Both
12. If yes, for which eyes(s)?
13. Visual acuity through bioptic telescope:
Right: 20/_______
Left : 20/_______
Both: 20/_________
☐Yes
☐No
14. Has the individual driven previously without a bioptic telescope?
☐Yes
☐No
15. Has the individual completed certified training in the use of a bioptic for driving?
16. Are there any other concerns regarding this individual’s fitness to safely operate a motor vehicle?
☐No
☐ Cognitive
☐ Physical
☐ Psychological
☐ Other:______________________________________________
17. What driving restriction(s), if any, do you recommend based upon your examination?
☐None
☐45mph limit/No interstate ☐Daylight only
☐Local driving only: _____miles from home
☐Should not drive
18. Other recommendations for highway safety purposes:
☐ Periodic vision evaluation:
☐ 6 months
☐every: circle: (1) (2) (3) year(s)
☐ On road evaluation by DMV (or approved examiner)
☐ Other:____________________________________________________________________________________________
Vision Examiner:
Name________________________________________________________Degree___________License #______________
Address_____________________________________________________________________________________________
Phone __________________________________________ Fax_________________________________________________
Signature_____________________________________________________Date___________________________________

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