Form D4 template
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Ophthalmologist Examination Report
An individual named (Patient's name) is seeking a waiver from Minnesota Department of Public Safety for intrastate school bus driving, following an ophthalmologist examination. The report requests information on the patient's diabetic condition's impact on visual health. The examining ophthalmologist should answer the following questions regarding the patient's: unstable proliferative diabetic retinopathy status, Snellen distant visual acuity (Left: 20/ Right: 20/), Horizontal Fields in Degree for each eye (Left Eye: _____ Right Eye: _____ BothEyes: _________), whether the patient reads with or without corrective lenses, and if their visual acuity is stable. The ophthalmologist should also provide their name, office/clinic name, telephone number, sign the report, and ensure that it has been examined within the preceding six months.
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