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omvsnS LICENSE NUMBER CASE NUMBER <br /> 2. Visual I5elds: <br /> O B a. Are there medical conditions that could affect patient's visual fields? <br /> b. If yes, list condition(s)and either attach a copy of visual fields testing, or fill in the <br /> amount of visual fields in each eye. <br /> Condition(s): <br /> Right eye Leftmyo:______degne*s <br /> O O H. HEARING'Initial if not applicable and skip this section. <br /> O O 1. Does patient have u hearing problem? |f yes, describe. <br /> UL CONCLUSION—Complete all items. <br /> *ox No <br /> o o A. *AT PATIENT'S LAST VISIT,WAS PATIENT'S CONDITION QR MEDICATIONS LIKELY <br /> TO INTERFERE WITH SAFE DRIVING? <br /> o o B. *IN YOUR OPINION, |8 THIS PERSON CAPABLE OF SAFE DRIVING? <br /> El o C. *DO YOU RECOMMEND A ROAD TEST? <br /> D. *IN YOUR OP|N|ON, HOW OFTEN SHOULD THIS PERSON'S DRIVING ABILITY BE <br /> REEVALUATED 8YTHE DK8V? Every_____year(o) <br /> E. *WHAT RENEWAL PERIOD DO YOU RECOMMEND FOR THIS DRIVER?(License terms: <br /> Age 1040=0-month provisional license until 19; 17-24=4 years;25-71 =8 years; 72+=2 <br /> years.) _______ymar(e) <br /> *These items must bncompleted, <br /> |oanify that| have examined this applicant. <br /> Print name of reporting physician Check one: 0 MID Date of examination Office telephone number <br /> 11 DO <br /> Signature of reporting physician Medical license number Specialty <br /> - <br /> ' <br />