Form Md-Fr 103 - Important Eye Examination Information Page 2
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2Name: _________________________________
Date of Birth: __________________
Address: ________________________________
License/History Number: _______________
City, State, Zip: __________________________
Telephone number: _____________
INSTRUCTIONS FOR COMPLETING EXAMINATION FORM
Please complete the eye examination form appropriately based upon your exam of the patient. Any additional comments can be
made at the bottom of this form.
Date of Examination: ___________________________
1. Visual Acuity
Without Glasses
With Present Glasses
With New Lenses
Right Eye
20/
20/
20/
Left Eye
20/
20/
20/
2. Visual Fields:
To Left of Points of Fixation ____________ Degrees To Right of Points of Fixation _____________ Degrees
Total Degrees = ________________________________________________________________________
(Degrees to Left Plus Degrees to Right Must Equal 140 or Greater for Unrestricted Licenses)
3. Are telescopic or low vision aids being used?
Yes
No
4. Is there definite ocular motility that is apt to produce diplopia or other safety hazards
Yes
No
If “Yes” explain: _______________________________________________________________________________
_____________________________________________________________________________________________
5. Because of possible progressive visual defect, applicant should be re-examined in _________________________
6. Recommendations: Corrective Lenses
Geographic or Area
Daylight Driving Only
None
7. Additional comments: ________________________________________________________________________
_____________________________________________________________________________________________
I hereby give my consent to release this information
____________________________
to the Secretary of State, State of Maine
Doctor’s Signature
____________________________
Doctor’s Name Printed
_______________________________________
____________________________
Signature of Person Examined
Address
____________________________
Telephone Number
MD-FR 103
Rev. 08/04/2014
MVE-103
Medical Review Section
29 State House Station, 101 Hospital Street, Augusta, ME 04333-0029
Phone: 207-624-9000 Ext. 52124 Fax: 207-624-9319 TTY: Maine Relay 711 Web:
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