Instructor
MEDICAL EXAMINATION REPORT
Michigan Department of State Driver Education Section 430 W. Allegan St. Lansing, MI 48918
Michigan Department of State
DES-N05 8/2019
PART A – RELEASE OF INFORMATION
Application for: ☐ Driver Education Instructor ☐ Driving Skills Examiner
Name of Applicant (Last, First, Middle)
Instructor’s Certificate Number
I hereby authorize and request that information regarding my medical condition be released to the Michigan Department of State and understand that the information provided may
be used to request an assessment of my driving privilege.
INSTRUCTIONS FOR PHYSICIAN
The Michigan Department of State requests your professional assistance to determine the physical and mental condition of the above patient. Your response to these
questions and any other pertinent information will help the MDOS assess the patient’s ability to safely operate a motor vehicle and to train others to operate a motor vehicle.
Confidential information may be mailed directly to the MDOS at the address shown above.
1. DEPIA MCL 256.637 (3)(j) Submits a certified medical examination report that is not older than 90 days and that is prepared by a physician, a physician’s assistant, or a certified nurse
practitioner licensed to practice in this state or in the applicant’s state of residence. The report shall include a statement by the person that certified the report that the applicant is medically
qualified to operate a motor vehicle and to train others to operate a motor vehicle.
PART B – HEALTH QUESTIONS
YES NO
1. Does patient have difficulty recognizing the colors of red, green, and amber used in traffic signal lights and devices?
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2. Is patient’s side (peripheral) vision less than 70º for either eye?
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3. Does patient have an acuity impairment in either eye that is not correctable to visual acuity of 20/40 or better?
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a. Have a missing foot, leg, hand, finger or arm?
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b. Have any impairment of a foot, leg, hand, finger or arm or any other limitation?
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5. Has patient had a heart attack, angina, coronary insufficiency, thrombosis, stroke, other heart problem, or cardiovascular disease?
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a. If “yes”, has patient had labored breathing, fainting, collapse, congestive heart failure, or other symptoms in the last two (2) years?
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6. Has patient been diagnosed with a respiratory condition, such as emphysema, chronic asthma, or tuberculosis?
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a. If “yes”, is patient’s respiratory condition likely to interfere with patient’s ability to drive a motor vehicle safely?
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7. Has patient been diagnosed with high blood pressure of 140/90 or higher?
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8. Has patient ever been diagnosed with rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular disease?
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a. If “yes”, is the condition likely to interfere with patient’s ability to drive a motor vehicle safely?
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9. Has patient been diagnosed with epilepsy or any other condition that may cause lapse of consciousness or loss of control?
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a. If “yes”, has there been a lapse of consciousness or loss of control in the last two (2) years?
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10. Does patient use a controlled substance, amphetamine, narcotic, or any other habit-forming drug or a history of alcoholism?
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11. Has patient been diagnosed with any mental, nervous, organic or functional disease, or psychiatric disorder?
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a. If “yes”, is the condition likely to interfere with patient’s ability to drive a motor vehicle safely?
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PART C – MEDICAL EXAMINER’S CERTIFICATION
To be completed by authorized physician.
I hereby certify that I am a physician, physician’s assistant, or a certified nurse practitioner licensed to practice in this state or in the applicant’s state of residence and
affirm that I have examined the applicant for any and all physical impairments or conditions that would preclude them from operating a motor vehicle and to train others to
operate a motor vehicle in accordance to MCL 256.637 (3)(j) and that the patient:
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Has no physical impairment or condition that would preclude them from operating a motor vehicle and to train others to operate a motor vehicle in accordance to MCL
256.637 (3)(j).
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Has a physical impairment or condition that would preclude or limit them from operating a motor vehicle and to train others to operate a motor vehicle [MCL 256.637
(3)(j)].
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Preclude the applicant from: TRAINING OTHERS TO OPERATE A MOTOR VEHICLE (NO Behind-the-Wheel Instruction.).
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Limit the applicant to:
TRAIN OTHERS TO OPERATE A MOTOR VEHICLE ONLY DURING THE DAYTIME HOURS.
Medical Examiner’s Signature
Date Medical Examination Report Completed
