MED 10 (07/01/2020)
Reason this patient's ability to walk is limited or impaired or creates a safety condition while walking. (check below)
Is restricted by lung disease to such an extent that
forced
(respiratory) expiratory volume for one second, when measured by
spirometry, is less than one liter, or the arterial oxygen tension is
less than 60 millimeters of mercury on room air at rest.
Is legally blind or deaf.
Cannot walk without the use of or assistance from any of the following:
another person, brace, cane, crutch, prosthetic device, wheelchair, or
other assistive device.
Is severely limited in ability to walk due to an arthritic, neurological, or
orthopedic condition.
Uses portable oxygen.
Has a cardiac condition to the extent that functional
limitations are
classified in severity as Class III or Class IV according to standards set
by the American Heart Association.
Has been diagnosed with a mental or developmental
amentia or
delay that impairs judgment including, but not limited to, an autism
spectrum disorder.
Has been diagnosed with Alzheimer's disease or another form of
dementia.
Other condition that limits or impairs the ability to walk, or creates a safety concern while walking because of impaired judgement or other physical,
developmental, or mental limitation (Specific condition description must be specified below).
Cannot walk 200 feet without stopping to rest.
Temporarily limited or impaired beginning date (mm/dd/yyyy) _____________ and ending date (mm/dd/yyyy)_________________(not to
exceed 6 months).
Permanently limited or impaired. A permanent disability as it relates to disabled parking privileges shall mean: a condition that limits or impairs
movement from one place to another or the ability to walk as defined in Virginia Code §46.2-1240, and that has reached the maximum level of
improvement and is not expected to change even with additional treatment.
NOTE: (This page does not have to be completed to renew permanent placards.)
LICENSED CHIROPRACTOR OR PODIATRIST MEDICAL CERTIFICATION
Reason this patient's ability to walk is limited or impaired. (check below)
Cannot walk without the use of or assistance from any of the
following: another person, brace, cane, crutch, prosthetic device,
wheelchair, or other assistive device.
Is severely limited in ability to walk due to an arthritic, neurological
or orthopedic condition.
Cannot walk 200 feet without stopping to rest.
I certify and affirm that the described applicant is my patient, whose ability to walk, based on my examination, is limited or impaired or creates a safety
concern while walking as described above.
I further certify and affirm that to the best of my knowledge and belief, all information I have presented in this form is true and correct, that any documents I
have presented to DMV are genuine, and that the information included in all supporting documentation is true and accurate. I make this certification and
affirmation under penalty of perjury and I understand that knowingly making a false statement or representation on this form is a criminal violation.
LICENSED PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER MEDICAL CERTIFICATION
LICENSED MEDICAL PROFESSIONAL CERTIFICATION
Physician
Physician Assistant
Nurse Practitioner
Chiropractor Podiatrist
DISABILITY TYPE
APPLICANT FULL LEGAL NAME (last, first, middle, suffix)
MEDICAL PROFESSIONAL NAME (print) OFFICE TELEPHONE NUMBER OFFICE FAX NUMBER
LICENSE TYPE LICENSE NUMBER STATE ISSUING LICENSE (required) LICENSE EXPIRATION DATE (required)
MEDICAL PROFESSIONAL SIGNATURE
DATE (mm/dd/yyyy)
page 2
The front of this form must be completed before
the medical professional signs the certification.
Other condition that limits or impairs the ability to walk (Specific condition description must be specified below).
