PATIENT’S NAME: ________________________________________________
4. Required:
Current Status of Condition:
(A) Controlled ■ (B) Not Controlled: will n
ot affect driving ■ (C) Not Controlled: may affect driving ■
(
If Not Controlled is marked, you must provide details, which may include pertinent clinical information, i.e., test results, lab
values.)
_______________________________________________________________________________________________________________
5. Required:
In the past six months, has the driver’s ability to safely operate a motor vehicle been impaired (due to any reason) or has
driver experienced an attack of unconsciousness? YES ■ NO
■ Date of Attack: ___________________
(
If YES, you must provide details, which may include pertinent clinical information.)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
6. Date of last impaired ability to safely operate a motor vehicle or attack of unconsciousness. Date: ___________________
(
You must provide details, which may include pertinent clinical information.)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
SECTION III — PROVIDER
1. How long have you been treating this driver? ______________________________________________________________________
2. Is the driver being treated by any other providers? YES ■ NO
■
3. If Question 2 is YES, name of physician and contact information: ______________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
NOTE: If treated by another provider, a statement regarding medical and mental fitness to operate a motor vehicle, or a
completed Medical Report is required by that provider.
SECTION IV — Additional information, special restrictions, etc.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
SECTION V — MD/DO and/or medical professional (NP/PA) — Failure to provide license information will result in return of form to
the driver.
(Unacceptable Signatures: Chiropractors, Podiatrists, Residents, Fellows, Interns, RN’s, LPN’s, Co-signatures)
MEDICAL:
______________________________________________________ _______________________________________________________
Provider Name (PRINTED) Medical Provider’s Address (PRINTED/STAMPED)
______________________________________________________ _______________________________________________________
Professional License Number/State License Issued Telephone Number
______________________________________________________ _______________________________________________________
Provider’s SIGNATURE — Date of Completion
■ MD ■ DO ■ NP ■ PA Provider’s Specialty
OTHER PROVIDER:
______________________________________________________ _______________________________________________________
Provider Name (PRINTED) Medical Provider’s Address (PRINTED/STAMPED)
______________________________________________________ _______________________________________________________
Professional License Number/State License Issued Telephone Number
______________________________________________________ _______________________________________________________
Provider’s SIGNATURE — Date of Completion
■ MD ■ DO ■ NP ■ PA Provider’s Specialty
PLEASE MAINTAIN A COPY FOR YOUR RECORDS.
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