Driver Vision Medical Evaluation Form
Please complete the Driver Vision Medical Evaluation Form to provide your vision screening details for evaluation.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Do you currently use any vision correction?
*
None
Glasses
Contact Lenses
Other
Distance Visual Acuity (with correction, if used)
*
Please Select
20/20 or better
20/25
20/30
20/40
Worse than 20/40
Near Visual Acuity (with correction, if used)
*
Please Select
20/20 or better
20/25
20/30
20/40
Worse than 20/40
Color Vision Screening Result
*
Normal
Deficient
Not Tested
Peripheral Vision (Field of Vision) Result
*
Normal
Restricted
Not Tested
Relevant Medical Conditions Affecting Vision (if any)
Date of Evaluation
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Evaluation
Should be Empty: