2010 BC Guide in Determining Fitness to Drive

21.18 Examination of visual functions form (EVF)EXAMINATION OF VISUAL FUNCTIONS (EVF)Paid for by the Office of the Superintendent of MotorVehicles through the MSP Billing System (see form back)PERSONAL HEALTH NUMBER(MUST BE COMPLETED)OPTOMETRISTSMSP Fee Code 96224(EVF Only)ORMSP Fee Code 96223(EVF and VFT)The personal information on this form is collected under the authority of the Motor Vehicle Act, Medicare Protection Act, and the Freedom of Information andProtection of Privacy Act. The information provided will be used to determine your fitness to drive a motor vehicle and allow the physician to bill through the BritishColumbia Medical Services Plan for the service. Personal information is protected from unauthorized use and disclosure in accordance with the Freedom ofInformation and Protection of Privacy Act and may be disclosed only as provided by that Act. If you have any questions about the collection, use and disclosure ofthe information collected, contact the Office of the Superintendent of Motor Vehicles at (250) 387-7747.THIS REPORT MUST BE COMPLETED IN FULL BY AN OPTOMETRIST AND RETURNED WITHIN 30DAYS TO THE OFFICE OF THE SUPERINTENDENT OF MOTOR VEHICLESDriver’s Name:DL#:Licence Class:Date Issued:Date of Birth:Reason for This Examination: This person has been referred to determine if he/she meets the vision guidelines forthe class of driver’s licence indicated above.1. BINOCULAR CENTRAL VISUAL ACUITYUNCORRECTED 20/ PRESENT CORRECTION 20/ BEST CORRECTION 20/2. BINOCULAR DEGREES OF CONTINUOUS HORIZONTAL FIELD OF VISION (WHILE WEARING CORRECTION)2.a BINOCULAR DEGREES OF CONTINUOUS FIELD OF VISION ABOVE AND BELOW FIXATION(WHILE WEARING CORRECTION)3. VISUAL FIELD DEFICIT NO YES IF YES, A VISUAL FIELD TEST IS REQUIRED.SEE REVERSE FOR APPROVED STUDY TYPES4. PROGRESSIVE EYE CONDITION NO YES IF YES, PROVIDE DIAGNOSIS AND DESCRIBE FULLY.5. DIPLOPIA IN CENTRAL FIELD(40 degrees) NO YES IF YES, HOW DOES THE DRIVER COMPENSATE?DESCRIBE FULLY6. OTHER SIGNIFICANT OCULARDEFECTS NO YES IF YES, PROVIDE DISGNOSIS AND DESCRIBE FULLY.7. WERE NEW LENSES FORDRIVING PRESCRIBED? NO YES281