DUI Field Evaluation Notes Subject Name Stop Time Hours : Minutes Arrest Time Hours : Minutes Horizontal Gaze Nystagmus1. Equal Tracking / 2. Equal Pupil SizeLack of Smooth Pursuit - Left Lack of Smooth Pursuit - Right Distinct nystagmus at max. deviation - Left Distinct nystagmus at max. deviation - Right Nystagmus prior to 45° - Left Nystagmus prior to 45° - Right Vertical nystagmus (not validated) - Left Vertical nystagmus (not validated) - Right Drug Influence Eye Exams (not validated)Contacts Y N Color Contacts Y N Lack of convergence Lack of convergence Pupil size - existing light Pupil size - existing light Pupil size - direct light Pupil size - direct light Pupillary reaction to light (within 1 sec) Pupillary reaction to light (within 1 sec) Walk & TurnInstruction StageCannot keep balance Cannot keep balance Starts too soon Starts too soon Walking StageStops Walking - 1st Nine Stops Walking - 2nd Nine Misses Heel-To-Toe 1/2" - 1st Nine Misses Heel-To-Toe 1/2" - 2nd Nine Steps off line - 1st Nine Steps off line - 2nd Nine Raises arms- 6" or more - 1st Nine Raises arms- 6" or more - 2nd Nine Actual steps taken - 1st Nine Actual steps taken - 2nd Nine Turns Improperly-Describe Shoes Comments One-Leg-StandLeg Raised - Left / RightPuts Foot Down Uses Arms for Balance Sways Hops Count Reached at 30 Seconds Comments Modified Romberg BalanceInternal Clock at 30 seconds Side to Side Sway Front to Back Sway Comments Section Finger to NoseSequence: Left, Right, Left, Right, Right, LeftComments Additional Tests or CommentsP.A.S. ResultsTest 1 Time Test 2 Time Serial Number Temp Investigation Interview - Spanish Investigation Interview - English Enter an email address to send a copy of the completed form to:(Required)