DLD-7 (Revised 7/2020)
10. Does the nature of the condition indicate loss/lapse of consciousness, seizure activity, fainting or dizzy
spells?
Yes* No
*If Yes, please indicate the date
(MM/DD/YYYY)
10a. Was the seizure or loss of consciousness an isolated incident? Yes No
10b. Are additional seizures likely to occur? Yes No
11. Please recommend any restrictions you feel are necessary for this patient to safely drive a vehicle:
12. Phy
sician’s Comments:
_____________________________________________
___________________________________________________________
_____________________________________________
____________________________________________________________
Signature of Authorized Physician, APRN or PA License Number
Physician Office Phone Number, APRN or PA
Please PRINT Name of Physician, APRN or PA
Office Address of Physician, APRN or PA
I hereby authorize any physician, surgeon, Advanced Practical Registered Nurse, Medical Assistant or other
person, and/or any clinic, or hospital, including the Department of Veterans Affairs or government hospital, to
release any and all acquired medical information that specifically addresses the information on this form and
may relate to, or affect my ability to operate a motor vehicle safely.
______________________________________________________________________________ ___________________________
Patient’s Signature Date
OPTIONAL: You can have an indicator of a medical condition imprinted on your driver’s license or identification
card to alert police and medical personnel. Your physician must state on this form that you suffer from any of
the medical conditions listed below. Check only one to be placed on the back of the license.
Anticoagulants (adverse effect)
Chronic Airway Obstruction
You
must present this form in person to the DMV if you wish to have one of these medical conditions imprinted
on your driver’s license or identification. There will be a $4.25 fee.
