Get Vision Examination Record Form

Dor. mo. gov FORM VISION EXAMINATION RECORD REV. 05-2013 PATIENT NAME LAST FIRST MIDDLE DRIVER OR PATIENT SECTION SOCIAL SECURITY NUMBER DATE OF BIRTH MM/DD/YYYY - - / / PATIENT MAILING ADDRESS CITY STATE ZIP CODE I hereby authorize and accept that My physician will conduct an eye examination to determine if my visual abilities are adequate to operate a motor vehicle safely and responsibly. MISSOURI DEPARTMENT OF REVENUE DRIVER LICENSE BUREAU P. O. BOX 200 TELEPHONE 573 751-2730 301 WEST HIGH STREET ROOM 470 FAX 573 522-8174 JEFFERSON CITY MO 65105-0200 WEB SITE www. The Driver License Bureau will make a final decision concerning my eligibility for driver licensure based on all available information* Signature of Driver or Patient must be signed in the presence of physician Date MM/DD/YYYY / / Yes Distance Acuity No Are you a regular or primary eye care provider for this patient PHYSICIAN If yes how many times have you seen this patient in the past year If no are you evaluating this patient for the first time today LEFT RIGHT Remarks special restrictions severity stability etc* BOTH W/O Correction 20/ Horizontal Field Width VISION GUIDELINES 20/40 or better in either eye or both corrected Corrective lenses A 20/100 or worse in left eye only no aid or corrected Left outside mirror Y Right outside mirror T 20/41 to 20/59 Daylight driving only AC 20/60 to 20/74 Based on my observations of this patient or information relayed to me by this individual I reasonably and in good faith believe that he or she is LIKELY CAPABLE of operating a motor vehicle safely and responsibly. There are no visual contradictions at this time. No further evaluation appears to be needed* UNCLEAR IF CAPABLE of operating a motor vehicle safely and responsibly due to current visual status. NOT CAPABLE of operating a motor vehicle safely and responsibly due to a significant visual compromise or deficit. If you are unclear if the patient is capable of operating a motor vehicle safely please submit a copy of this form to DLB. DriverReviewProcessing dor. mo. gov or mail to the address above. OFFICE MAILING ADDRESS INCLUDING ZIP CODE SPECIALITY PHONE FAX - PHYSICIAN NAME PRINTED LICENSE NUMBER SIGNATURE DATE MM/DD/YYYY / / For further information on Department policies and restrictions go to www. The Driver License Bureau will make a final decision concerning my eligibility for driver licensure based on all available information* Signature of Driver or Patient must be signed in the presence of physician Date MM/DD/YYYY / / Yes Distance Acuity No Are you a regular or primary eye care provider for this patient PHYSICIAN If yes how many times have you seen this patient in the past year If no are you evaluating this patient for the first time today LEFT RIGHT Remarks special restrictions severity stability etc* BOTH W/O Correction 20/ Horizontal Field Width VISION GUIDELINES 20/40 or better in either eye or both corrected Corrective lenses A 20/100 or worse in left eye only no aid or corrected Left outside mirror Y Right outside mirror T 20/41 to 20/59 Daylight driving only AC 20/60 to 20/74 Based on my observations of this patient or information relayed to me by this individual I reasonably and in good faith believe that he or she is LIKELY CAPABLE of operating a motor vehicle safely and responsibly. There are no visual contradictions at this time. No further evaluation appears to be needed* UNCLEAR IF CAPABLE of operating a motor vehicle safely and responsibly due to current visual status.