Report Of Eye Examination
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1
2Florida Highway Patrol
REPORT OF EYE EXAMINATION
DATE OF EXAMINATION:
NAME
Social Security Number__________________________ Age ____________________Sex _____________
PAST HISTORY:
Have you ever had your eyes examined in the past?
YES
NO
Have you ever had an eyesight deficiency brought to your attention?
YES
NO C
Do you now wear corrective lenses to aid your eyesight?
YES
NO
Have you ever received medical treatment for your eyes?
YES
NO
If YES, describe
Signature of Applicant
EXAMINATION
Minimum Corrected Vision of 20/30 in Each Eye
Wears Glasses or Contact Lenses: Near Only_________ Distant Only_________ Constant__________
1. ACUITY
UNAIDED
WITH CORRECTION
Right 20/
Right 20/
DISTANT ACUITY:
Left 20/
Left 20/
__________________
Both 20/
Both 20
/
Right
201
Right 20
/
NEAR ACUITY:
Left 20/
Left 20/
__________________
__________________
Both
20/
Both 20 /
2. COLOR PERCEPTION
Ishihara or Equivalent
3. FUSION
4. DEPTH PERCEPTION
PHORIA: Vertical___________________________________
Lateral___________________________________
5. E.O.M.
6. FIELD OF VISION
7. OPHTHALMOSCOPY
Physician’s Remarks:
ACCEPTANCE RECOMMENDED? YES
NO
Signature of Vision Specialist
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Parent category: Medical