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EYE SIGHT

If you are unsure of the answers, it would be advisable to discuss the form with your doctor.

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First Name
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Last Name
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Address
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Phone Number:
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E-mail Address
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Please answer all questions:

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1. a. Can you read a number plate from 20 metres in good light with glasses or contact lenses if worn?
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b. Has your doctor or optician advised you that your eyesight does not currently meet the minimum standard for driving? Visual acuity of 6/ 12(0.5) or better must be achieved with the aid of glasses or contact lenses if necessary.
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c. Has your doctor or optician advised you that your eyesight does not currently meet the minimum standard for vocational driving? Visual acuity of at least 6/7.5 (0.8) in the better eye and 6/60 (0.1) in the other eye must be achieved with the aid of glasses or contact lenses if necessary
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2. a. Do you need to wear glasses or contact lenses to meet the minimum eyesight standard when you drive cars or motorcycles?
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3. Do you have any of the following

a) Ocular hypertension
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b) Glaucoma
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c) Retinitis Pigmentosa
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d) Laser treatment or injections into both eyes (and remaining eye if one eye only) for diabetic eye disease or another eye condition?
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You stated you had laser treatment or injections above - please provide the date of your last treatment
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e) Macular degeneration or any other macular Disease
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f) Cataracts or any corneal dystrophies e.g., Fuchs? (Do not tick if you have had successful surgery to remove cataracts)
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4. Do you have any other medical condition not specified at question 3 affecting either eye?
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You answered yes to the above question - please state which eye is effected
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Please provide details about your medical condition
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5. Has your doctor or optician ever told you that you have a visual field defect? (Do not include long or short sightedness)
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6. Do you have total loss of sight in one eye?
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You answered yes, please give date of loss
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7. Do you have double vision (diplopia)?
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a) You answered yes, do you ensure any double vision is suppressed or controlled when driving?
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b) Please tick in the box below how the double vision is controlled
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c) You indicated 'other' - please specify
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8) Have you had cataracts removed?
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9. Please give details of all medication taken by you including eye drops
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10. Please supply the dates below of any phone, video, or face to face consultations for this condition?
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11) a. Last Date of Opticians Eye Sight Test
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b) Results of Eye Sight Test
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c) Please Provide Full Name and Address of Opticians
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Declaration

I declare that I have checked the details I have given on the enclosed questionnaire and that, to the best of my knowledge and belief they are correct. I understand that it is a criminal offence if I make a false declaration to obtain a driving licence and can lead to prosecution.

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Signature:
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Date:
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