Form DR 2402 template
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Confidential Eye Examination Report
The document is an eye examination report for a patient, which includes sections for the driver and the physician or optometrist. The document outlines the patient's last name, first name, middle initial, address, customer identification number, date of birth, and signature. The driver section contains a statement of understanding regarding the eye examination, determining fitness to operate a motor vehicle safely, and potential consequences for the form's submission. The physician or optometrist section instructs them to use their best clinical judgment in completing all sections based on Colorado Vision Recommendations, which include a visual acuity requirement with and without corrective lenses and a total combined horizontal field of vision of at least 120 degrees. The examination information includes checkboxes for progressive ocular conditions, visual field deficits, and additional information such as distance acuity, bioptic lens usage, and horizontal perception fields.
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