STATE OF CALIFORNIA
DEPARTMENT OF MOTOR VEHICLES®
A Public Service Agency
962
REPORT OF VISION EXAMINATION
SECTION 1 — APPLICANT COMPLETES THIS SECTION
INSTRUCTIONS: Please complete the driver license number, date of birth, telephone number, name, and address areas of this form. You must sign and date the authorization line. All medical information received by the Department of Motor Vehicles (DMV) is conidential under
California Vehicle Code (CVC) §1808.5. Please bring this completed form and any new corrective lenses with you when you return to DMV for further testing. If any section of this form is incomplete, it may have to be returned to the vision specialist for completion. DO NOT MAIL THIS FORM BACK TO DMV unless asked to do so by a DMV employee. Alterations or erased information may void this form.
Your vision specialist should conduct a new vision examination unless one has been conducted within the last six months. DMV will make the inal licensing decision based on a combination of factors, including information from your vision specialist.
DRIVER LICENSE NUMBER
NAME (FIRST, MIDDLE, LAST)
DATE OF BIRTH (MO., DAY, YR.)
RESIDENCE ADDRESS |
CITY |
STATE |
ZIP CODE |
I authorize the vision specialist conducting this examination to provide the Department of Motor Vehicles with the following
information for its conidential use (CVC §1808.5) in evaluating my ability to safely operate a motor vehicle.
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20/40 with both eyes tested together, and |
DMV’s Visual Acuity Screening Standard is |
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20/40 in one eye, and |
• 20/70, at least, in the other eye.
SECTION 2 — OPHTHALMOLOGIST OR OPTOMETRIST COMPLETES THOSE SECTIONS THAT APPLY — Information must be from exam within last 6 months.
1. REFRACTION — Complete only those sections that apply.
HAVE NEW DISTANCE LENSES BEEN PRESCRIBED AND FITTED?
Yes |
No If yes: |
Glasses |
Contact Lenses |
DATE NEW LENSES WERE PRESCRIBED
IS NIGHT DRIVING RECOMMENDED?

Yes
No
IS MONOVISION EMPLOYED? |
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DID YOUR PATIENT RECEIVE BIOPTIC LENS TRAINING? |
By contact lenses |
Yes |
No |
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Yes |
No |
Not Known |
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By refractive surgery |
Yes |
No |
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DID PATIENT RECEIVE BIOPTIC LENS TRAINING THAT INCLUDED DRIVING? |
Is best corrected visual acuity in each eye recommended for driving? |
Yes |
No |
Yes |
No |
Not Known |
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Bioptic Telescope |
Right eye 20/ ___________ |
Left eye 20/___________ |
SKILL IN USING BIOPTIC TELESCOPE |
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Bioptic Telescope suitable for driving? |
Yes |
No |
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Satisfactory |
Unsatisfactory |
Not Known |
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2. VISUAL ACUITY — Complete Clinical Measurement Section. Lenses include contact lenses or glasses.
DMV MEASUREMENT (FOR DMV USE ONLY) |
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CLINICAL MEASUREMENT (WITHOUT BIOPTIC TELESCOPE) |
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Both Eyes |
Right Eye |
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Left Eye |
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Both Eyes |
Right Eye |
Left Eye |
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Without Lenses |
20/ |
20/ |
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20/ |
Without Lenses |
20/ |
20/ |
20/ |
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With Current Lenses |
20/ |
20/ |
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20/ |
With Lenses |
20/ |
20/ |
20/ |
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Best Corrected Visual Acuity |
20/ |
20/ |
20/ |
3.DIAGNOSIS — Please indicate vision condition by checking the box(es) representing affected eye(s). If the diagnosed condition is not listed, write the diagnosis under “other diagnosis/comments” below.
REFRACTIVE R L DEVELOPMENTAL
Astigmatism |
Amblyopia |
Hyperopia |
Strabismus |
Myopia |
Congenital Nystagmus |
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Albinism |
R L OPTICAL |
R L RETINAL/OPTIC NERVE R L |
Cataract |
Diabetic Retinopathy |
Corneal Opacity |
Macular Degeneration |
Diplopia (uncorrectable) |
Glaucoma |
Keratoconus |
Retinal Detachment |
Aphakia |
Retinitis Pigmentosa |
Pseudophakia |
Retinal Damage |
Post. Caps. Opac. |
(CRVO, PRP etc.) |
VISUAL FIELDS |
R L |
Decreased Peripheral Vision |
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Hemianopia |
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Quadrantanopia |
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Decreased Peripheral Vision. Please identify the areasaffectedonthechartinSection5(seereverse)
Other diagnosis/comments
Monocular Vision (No Light Perception or Prosthesis) |
If monocular, when was the monocular vision diagnosed? |
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If monocular, does the patient have a medical condition that could affect the functional eye in the future? |
Yes |
No |
Any eye surgery (including refractive)? |
Yes |
No |
Date of most recent surgery |
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Type of surgery |
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DL 62 (REV. 4/2016) WWW |
*DL62* |
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Diagnosis |
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Static |
Diagnosis |
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Static |
Diagnosis |
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Static |
Progressive |
Stable since |
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(date) |
Progressive |
Stable since |
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(date) |
Progressive |
Stable since |
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(date) |
WHEN SHOULD DMV REQUIRE A NEW DMV VISION EXAMINATION REPORT FORM BE SUBMITTED?

Not applicable
1 year 
2 years
5 years 
Other
5.VISUAL FIELDS — If vision is not correctable to 20/40 in each eye, or there is possible visual ield loss, a full visual ield examination (con- frontation is permissible) must be performed. Show the approximate peripheral extent and any scotomas in the diagram below.
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LEFT EYE |
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RIGHT EYE |
Extent: |
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Extent: |
Left |
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Left |
Right |
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Right |
Up |
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Up |
Down |
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Down |
6.VISUAL ABNORMALITIES — The following information will help our examiners evaluate your patient’s ability to safely operate a motor vehicle. Based upon your testing, clinical impression, or knowledge of the disorder, please indicate the severity of any of the following visual abnormalities which your patient may be experiencing. Indicate severity of condition by placing a 1 (mild), 2 (moderate), or 3 (severe) in the box(es) below.
R L
Decreased Acuity
Color Defect
R L
Visual Field Loss
Reduced Depth Perception
7. ADVICE — Have you given your patient any advice about driving? |
Yes |
No |
If yes, please explain in #8 below. |
8.ADDITIONAL COMMENTS — Report any additional information or comments you feel DMV should know concerning your patient’s visual and perceptual capabilities relating to driving performance. You may use an additional sheet of paper to provide this information as well as
information about any existing conditions which contribute to poor night vision or poor depth perception, etc. Any recommendations about the patient’s general safety should also be made. DMV will make the inal licensing decision based on a combination of factors, including your professional expertise.
9. SIGNATURE — This section must be completed to validate this report.
PRINTED NAME |
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M.D. OR O.D. LICENSE NUMBER |
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SIGNATURE |
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DATE OF EXAM (MUST BE WITHIN LAST 6 MONTHS) |
X |
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ADDRESS |
CITY |
CA |
ZIP CODE |
TELEPHONE NUMBER |
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