Fillable Printable Dl Ophthamologist Examination Report

Dl Ophthamologist Examination Report

AN EQUAL OPPORTUNITY EMPL OYER

445 MINNESOTA ST., SUITE 180

ST. PAUL, MN 55101-5180

651/ 297-5029 VOICE

651/ 297-4447 FAX

651/ 282-6555 DEVICE FOR HEARING IMPAIRED

STATE OF MINNESOTA

DEPARTMENT OF PUBLIC SAFETY

OPHTHALMOLOGIST EXAMINATION REPORT

Dear Ophthalmologist:

(Patient's name) ______________________________ who appears before you is applying to the Minnesota

Department of Public Safety for a waiver from the medical standards for intrastate school bus driver. We must have

inf orm ation as to whether the pat ient's diabeti c condi ti on has had an ef f ect on his/her v i sual heal t h. Pl ease ex am ine t he

patient according to the criteria listed below, and answer each question accordingly. Finally, please sign and date the

report.

Does this patient have unstable proliferat ive diabeti c r etinopat hy ? YES NO

What is this patient ' s di stant visual ac uit y ( S nellen) ? Left : 20/ Right: 20/

What is this patient's Horizontal Fields in Degree? Left Eye:_______ Right Eye:_______ Both

Eyes:_________

Is this readi ng with or without c or r ec tive lenses? WITH WITHOUT

Is the pat ient's vi sual ac uity stable? YES NO

Opht halmol ogist’s nam e ( please print )

Office/clinic name and telephone number

Signature Date of examinat ion

Must have been examined within preceding s i x m ont hs .

D4 (Ophthalmologist Exami nation Report 2010)