Form 22z - Eye Examination - New Scotia
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1Service Nova Scotia
1505 Barrington Street
Eye Examination
9 North
and Municipal Relations
Halifax, Nova Scotia
Motor Vehicle Administration
B3J 3K5
Tel: (902) 424-5732
Fax: (902) 424-0772
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This form must be completed by an Optometrist or Ophthalmologist.
Patient Information and Consent
Name: ____________________________________________________
Date of Birth: ______________________________________________
Address: __________________________________________________
Telephone: Home (
) _____________ Work (
) _____________
__________________________________ Postal Code: ____________
Cellular (
) _____________
x y z { | } ~
Master No: ________________________________________________
Class of licence (check one):
I authorize a vision specialist to report their findings to the Motor Vehicle Administration Section.
_____________________________________________________________________________________
___________________________________________________
PATIENT’S/DRIVER’S SIGNATURE
DATE
I, __________________________________________________________________, being licensed to practice ophthalmology/optometry in the
Province of Nova Scotia, have examined the person named above and find the following:
For classes 3, 5, 6, 7 and 8, visual acuity must
VISUAL ACUITY
Right eye
Left eye
be at least 20/40 (6/12) in better eye.
Vision uncorrected (Snellen Chart)
For classes 1, 2, and 4, visual acuity must be at
least 20/30 (6/9) in better eye and 20/50 (6/15)
Vision with correction (Snellen Chart)
in poorer eye.
Colour vision (can accurately identify red, green and amber)
Yes
No
K
K
Any diplopia?
Yes
No
K
K
Is there evidence of eye disease or injury?
Yes
No
K
K
If “Yes,” please provide diagnosis/condition __________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
VISUAL FIELD
For classes 3, 5, 6, 7 and 8, visual field must be
at least 120° with both eyes opened and
examined together.
For classes 1, 2, and 4, visual field must be at
least 120° in each eye examined separately.
Any visual field defects?
Yes
No
K
K
If “Yes,” please explain __________________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Does this patient meet the vision standards required to safely operate the class of motor vehicle as checked above?
Yes
No
K
K
Does patient:
need corrective lenses for driving?
Yes
No
need a daylight driving only restriction?
Yes
No
K
K
K
K
have the recommended correction?
Yes
No
K
K
Is follow up required?
Yes
No
If yes, when _____________________________________________________
K
K
Ophthalmologist/Optometrist’s Information
Address: ________________________________________________________________________________________________________________
City/Town: __________________________________ Province: __________________________________ Postal Code: _______________________
Telephone: (
) ________________________ Fax: (
) ________________________
_____________________________________________________________________________________
___________________________________________________
OPHTHALMOLOGIST/OPTOMETRIST’S SIGNATURE
DATE
CER12 Form 22Z Rev 11/07
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