North Carolina Department Of Motor Vehicles Vision Specialist Form Dl77 printable pdf download

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?

☐ 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

Test used: ☐ Confrontation

☐ Goldmann

☐ Automated

9. Are there other visual issues that might affect driving?

☐ 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___________________________________

North Carolina Department Of Motor Vehicles Vision Specialist Form Dl77

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