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Med2 CUSTOMER MEDICAL REPORT (Virginia Department of Motor Vehicles)

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MED 2 (07/01/2020)
CUSTOMER MEDICAL REPORT
Describe, in detail, your medical condition.
WEIGHT
HEIGHT
FT INlbs
BIRTH DATE (mm/dd/yyyy)
Do you take prescription/non-prescription medications?
If Yes, list below. (attach a separate sheet if more space is required)
YES NO
NON-PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN
Have you ever experienced a blackout, seizure, loss of consciousness, or syncope?
If Yes, enter date of last episode.
Did the episode result in a motor vehicle crash?
YES NO
DATE (mm/dd/yyyy)
YES NO
Explain what happened during the episode.
INFORMATION RELEASE APPROVAL
CUSTOMER SIGNATURE AND AUTHORIZATION (parent must sign for a minor)
COMMERCIAL DRIVER LICENSE DISABILITY WAIVER OR HAZARDOUS MATERIALS VARIANCE
Are you applying for a commercial driver license disability waiver or a hazardous materials variance?
If YES, a CDL Disability Waiver or Hazardous Materials Variance Application (MED 30) must also be submitted.
I authorize ________________________________________________ and/or_______________________________________________________,
a licensed medical provider to complete this Customer Medical Report, submit it to DMV and, if necessary to provide further clarification or information
to DMV about my physical and/or mental condition. I consent to DMV using this information to arrive at a decision concerning my ability to safely
operate a motor vehicle. I also authorize DMV to use the above customer information to correctly identify my records on file in accordance with the
Virginia Privacy Protection Act of 1976. I understand that Virginia Code
§ 46.2-208(b)(1) prohibits DMV from releasing medical data to anyone other
than a physician, physician assistant or nurse practitioner
MAILING ADDRESS
CITY STATE ZIP CODE
DAYTIME TELEPHONE NUMBER
YES NO
DATE (mm/dd/yyyy)
RESIDENCE/HOME ADDRESS
CITY STATE ZIP CODE CITY OR COUNTY OF RESIDENCE
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER (from your driver's license) or SSN
CUSTOMER INFORMATION
Purpose: Use this form to request medical information from your physician, physician assistant or nurse practitioner.
Instructions: Follow the detailed INSTRUCTIONS printed on page 2. Complete the Customer Information and Information Release
Approval sections on this page. Take the entire MED 2 and DMV letter to your physician, physician assistant or nurse
practitioner to complete the sections that pertain to your medical condition. Part F must be completed by your physician,
physician assistant or nurse practitioner. Note: Any charges related to or incurred as part of the completion of this form
are the customer's responsibility.
NOTE: If you enter a residence or mailing address that is other than what is currently on DMV's system, complete an
"Address Change Request" (ISD 01).
MED 2 (07/01/2020)
CUSTOMER INSTRUCTIONS
1. Review all correspondence received from the Department of Motor Vehicles (DMV) regarding concerns about your
ability to safely operate a motor vehicle.
n If you received an Official Notice/Order of Suspension, you must provide DMV with the required Customer
Medical Report (MED 2), prior to the effective date noted in the Notice/Order to avoid having your driving
privilege suspended.
n If your driving privilege is suspended, you will be required to provide proof of legal presence in order to reinstate
your driver's license, if you have not already provided proof.
2. Complete the sections of the MED 2 titled “Customer Information” and “Information Release Approval”. Be sure to
provide your signature at the end of the “Information Release Approval” section.
3. Take the entire MED 2 and your DMV letter to your medical provider at the time of your medical examination.
4. Request your medical provider to complete the parts of the MED 2 that pertain to your medical condition(s) and
Part F and return the report to DMV (following medical provider instructions below).
n The medical examination must be conducted after the issue date of your Official Notice/Order of Suspension.
n If you were involved in a recent motor vehicle crash or have experienced a recent blackout, seizure or loss of
consciousness, the MED 2 report must reference these incidents and/or events.
Note: you will be notified of any decisions regarding your driving privilege based on:
m Medical and other related information received from your medical provider,
m DMV driver license test results and/or a certified independent driver rehabilitation evaluation (if required),
m DMV medical review policies and guidelines as established in collaboration with the DMV Medical Advisory
Board.
5. If you have questions related to DMV's requirement for you to submit a MED 2, you may contact DMV Medical
Review Services:
n Mail - send your request in writing to Medical Review Services at the address listed at the top of this form
n Telephone - (Voice) 1-804-367-6203 or (Deaf/Hearing Impaired only) 1-800-272-9268
Purpose: Use these instructions to complete the Customer Medical Report (MED 2).
CUSTOMER MEDICAL REPORT
INSTRUCTIONS
Page 2
MED 2 (07/01/2020)
1. The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your
patient's ability to safely operate a regular motor vehicle and/or commercial motor vehicle. DMV is concerned about
any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion
m judgment/cognitive function m reaction time
2. DMV may have requested these documents for one of three reasons:
n DMV received a crash report, Medical Review Request Form, or a court
document that requires a medical evaluation. Please refer to the customer explanation letter that describes the
issue of concern that needs to be addressed. Each form, A-E, has a section to complete regarding the issue.
Please supply a medical opinion on the area of concern and attach any relevant lab work or test results.
If your patient was involved in a recent motor vehicle crash or has experienced a recent blackout, loss of
consciousness, or seizure, the MED 2 must include specific information that may have contributed to the
incident(s) and/or event(s).
n DMV is requesting these forms for a patient we have under periodic review.
Please be sure to address the patient's ongoing stability, any episode of instability, or any decline in the patient's
condition. Please note any new conditions that may interfere with safe driving.
n A patient self-reported on their application a medical condition or a
medication that may indicate a medical condition that DMV evaluates for driver safety.
3. Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's
medical condition(s).
n For medical conditions, complete one or more of the following specific report sections:
m Neurological/Musculoskeletal - Part A & F
m Metabolic - Part B & F
m Cardiovascular - Part C & F
m Pulmonary - Part D & F
m Psychiatric/Substance Abuse - Part E & F
NOTE: Only one Part F is required if the same medical provider completes multiple report sections.
4. In lieu of completing the MED 2, you may submit a letter, note or copies of records as long as the information you
submit addresses all of the information requested on the MED 2 including your determination on the patient's ability
and safety to drive.
5. Return the completed MED 2 to DMV by faxing it to DMV Medical Review Services at (804) 367-1604 or (804)
367-0520.
6. For additional information on DMV's medical review process, you may refer to www.dmvnow.com under "Citizen
Services", then "Medical Information", or contact Medical Review Services at 804-367-6203.
MEDICAL PROVIDER INSTRUCTIONS
CUSTOMER MEDICAL REPORT
INSTRUCTIONS
Page 3
MED 2 (07/01/2020)
Customer Medical Report
PART A - NEUROLOGICAL/ MUSCULOSKELETAL REPORT (must also complete Part F)
Was the hospitalization voluntary?
Is adaptive equipment recommended? If Yes, what type of adaptive equipment does the patient require?
NOYES
Does the neuropathy affect the patient's ability to safely operate a motor vehicle?
NOYES
Does the patient suffer from muscle spasms?
NOYES
Does the patient have full range of motion of the head and neck? If No, describe range of motion.
NOYES
Current blood levels of anticonvulsant medication TEST DATE (mm/dd/yyyy) Results of most recent EEG
Does the patient suffer from peripheral neuropathy? If Yes, which extremities are impaired?
NOYES
Does the patient have any chronic conditions, chronic pain syndromes, fibromyalgia or any movement disorders? If Yes, specify.
NOYES
Is the patient prescribed medication for chronic pain or long-acting narcotics? If Yes, list the medication(s).
NOYES
Does the patient have the use of all extremities? If No, which extremities are impaired?
NOYES
Does the patient have any motor deficits/nerve problems that would impair his/her ability to drive?
YES NO
Does the patient have any other neurological condition(s) that might affect his/her driving? If Yes, describe the condition(s) and its effect on the
patient's driving.
NOYES
EXAMINATION DATE (mm/dd/yyyy)
Have you examined this individual during the last six months?
NOYES IF Yes, enter examination date.
Length of time individual has been your patient.
YEARS MONTHS
DIAGNOSIS(ES) (In order of severity or by current treatment)
Are there any complications related to this/these condition(s)? If Yes, explain.
NOYES
Has the patient been hospitalized for the above condition(s) within the past year? If Yes, list dates hospitalized and status upon discharge.
YES NO
YES NO
Does the patient have a history of seizures? If Yes, provide date of each episode and reason(s).
NOYES
Indicate the risk for further episodes.
DATE OF CRASH (mm/dd/yyyy)
Did any seizure result in a motor vehicle crash? If Yes, enter date of crash.
YES NO
BLOOD TEST RESULTS
Was the last medication blood serum level within acceptable range? If No, provide results of blood test.
NOYES
Did the patient have a blackout or syncope? If so, what was the cause? (Please enclose documentation to support the cause; such as results of lab
work and blood pressures to support dehydration, high fever, etc.)
NOYES
If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.
Go to Part F
The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time
Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER or SSNBIRTH DATE (mm/dd/yyyy)
Page 4
N/A for this customer
MED 2 (07/01/2020)
Does the patient monitor his/her blood sugar? If Yes, how often?
Attach the following information/documents, If you suffered a hypoglycemic event, please ensure that your blood sugar logs reflect the last 15 days and your A1C results are
drawn after the incident occurred and within the last 30 days.
Blood Sugar Logs (15 days)
Hemoglobin A1C Results (30 days)
Has this patient been hospitalized for treatment of diabetes/hypoglycemia or complications in the past year? If Yes, explain
NOYES
NOYES
Attached
Attached
Was the hospitalization voluntary?
DIAGNOSIS(ES) (In order of severity or by current treatment)
Are there any complications related to this/these condition(s)? If Yes, explain.
NOYES
Has the patient been hospitalized for the above condition(s) within the past year? If Yes, list dates hospitalized and status upon discharge.
YES NO
YES NO
Does the patient have diabetes or any other metabolic condition(s) that might affect vehicle operation? If Yes, indicate condition.
NOYES
Do any complications or associated conditions exist? If Yes, explain.
NOYES
Does this patient have hypoglycemic reactions? If Yes, provide dates and reasons.
NOYES
Did the hypoglycemic reaction(s) result in a motor vehicle crash(es)?
YES NO
Does this patient demonstrate how to counter a hypoglycemic reaction? If Yes, explain how.
NOYES
EXAMINATION DATE (mm/dd/yyyy)
Have you examined this individual during the last six months?
NOYES IF Yes, enter examination date.
Length of time individual has been your patient.
YEARS MONTHS
If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.
Go to Part F
PART B - METABOLIC REPORT (must also complete Part F)
Customer Medical Report
The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time
Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER or SSNBIRTH DATE (mm/dd/yyyy)
Page 5
N/A for this customer
MED 2 (07/01/2020)
PART C - CARDIOVASCULAR REPORT (must also complete Part F)
Has the patient had any of the following:
Attach the following information/documents:
DIAGNOSIS(ES) (In order of severity or by current treatment)
EXAMINATION DATE (mm/dd/yyyy)
Have you examined this individual during the last six months?
NOYES IF Yes, enter examination date.
Length of time individual has been your patient.
YEARS MONTHS
Was the hospitalization voluntary?
Are there any complications related to this/these condition(s)? If Yes, explain.
NOYES
Has the patient been hospitalized for the above condition(s) within the past year? If Yes, list dates hospitalized and status upon discharge.
YES NO
YES NO
Does the patient have an implantable cardioverter defibrillator? If Yes, give implant date.
YES NO
Has the unit discharged since the implant? If Yes, describe the patient's condition at the time and date of discharge.
YES NO
Does the patient have a ventricular assist device system? If Yes, when was this device implanted?
YES NO
Cardiovascular surgery and/or other procedures? If Yes, explain and give dates.
NOYES
Syncope? If Yes, explain and give dates.
NOYES
Results of Event Monitor
Results of Holter Monitor
Results of Tilt-table Test
Results of EKG
Fatigue with exertion? Fatigue at rest?
YES NO
YES NO
Dyspnea with exertion? If Yes, explain and give dates.
YES NO
Dyspnea at rest? If Yes, explain and give dates.
YES NO
Pulmonary symptoms? If Yes, explain and give dates.
YES NO
If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.
Go to Part F
Customer Medical Report
The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time
Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER or SSNBIRTH DATE (mm/dd/yyyy)
Page 6
N/A for this customer
MED 2 (07/01/2020)
PART D - PULMONARY REPORT (must also complete Part F)
Go to Part F
Customer Medical Report
The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time
Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER or SSNBIRTH DATE (mm/dd/yyyy)
DIAGNOSIS(ES) (In order of severity or by current treatment)
EXAMINATION DATE (mm/dd/yyyy)
Have you examined this individual during the last six months?
NOYES IF Yes, enter examination date.
Length of time individual has been your patient.
YEARS MONTHS
Was the hospitalization voluntary?
Are there any complications related to this/these condition(s)? If Yes, explain.
NOYES
Has the patient been hospitalized for the above condition(s) within the past year? If Yes, list dates hospitalized and status upon discharge.
YES NO
YES NO
Is oxygen use required? If Yes, describe treatment regimen and provide number of liters.
YES NO
Fatigue with exertion? Fatigue at rest?
YES NO
YES NO
Dyspnea with exertion? If Yes, explain and give dates.
YES NO
Dyspnea at rest? If Yes, explain and give dates.
YES NO
Syncope from cough? If Yes, explain cause and resolution.
YES NO
Does the patient have a diagnosis of sleep apnea, narcolepsy, or other sleep disorder?
(describe the treatment and submit a CPAP report for moderate to severe sleep apnea).
YES
mild moderate severe
NO
Does the pulmonary disease prevent activities of daily living? If Yes, identify.
YES NO
Has patient been compliant with treatment to the extent that the symptoms are controlled?
YES NO
Results of sleep study
Results of pulmonary function test
Pulse oximetry room air oxygen
If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.
Can the patient maintain O2 Saturation level of 90% or higher when driving?
YES NO
Attach the following information/document if available
Page 7
N/A for this customer
MED 2 (07/01/2020)
Has the patient been compliant with substance abuse treatment?
NOYES
Recommendations:
Report from substance abuse counselor
Results of drug/alcohol screening
Attach the following information/documents:
Does the patient have a condition, which results in one or more of the impairments listed below? If Yes, check all that apply.
Attach the following information/documents, (if available):
MMSE
Neuropsychological Exam
attached not available
attached
not available
Go to Part F
DIAGNOSIS(ES) (In order of severity or by current treatment)
EXAMINATION DATE (mm/dd/yyyy)
Have you examined this individual during the last six months?
NOYES IF Yes, enter examination date.
Length of time individual has been your patient.
YEARS MONTHS
Was the hospitalization voluntary?
Are there any complications related to this/these condition(s)? If Yes, explain.
NOYES
Has the patient been hospitalized for the above condition(s) within the past year? If Yes, list dates hospitalized and status upon discharge.
YES NO
YES NO
Has the patient been hospitalized in the past year for a mental/emotional condition? If Yes, give admission date(s), reason(s) for admission and date
(s) of discharge.
YES NO
NOYES
Poor decision-making/problem-solving skills
Memory loss, Cognitive
Poor impulse control/extremely impulsive Emotional or behavioral instability
Extremely aggressive/destructive behavior
Hallucinations/delusions
Dementia/confusion
Poor/impaired judgement
Identify current treatment program(s), counseling, medications, etc.
Is patient CURRENTLY undergoing OR has patient successfully completed drug/alcohol treatment? If Yes, please provide name of program.
NOYES
If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.
Did the patient experience seizure(s) related to withdrawal? If Yes, give date(s).
NOYES
PART E - PSYCHIATRIC/SUBSTANCE ABUSE REPORT (must also complete Part F)
Customer Medical Report
The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time
Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER or SSNBIRTH DATE (mm/dd/yyyy)
Page 8
N/A for this customer
MED 2 (07/01/2020)
Customer Medical Report
(MUST BE COMPLETED BY PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER)
PART F - GENERAL RECOMMENDATIONS
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER or SSNBIRTH DATE (mm/dd/yyyy)
Page 9
Based on this examination, the patient's driving ability is likely to be impaired by limitations in the following areas: (check each appropriate item)
Judgment and Insight Sensorimotor Function
Based on this examination, patient needs the following: (check each appropriate item)
For clarification on any of the above, contact Medical Review Services at 804 367-6203.
Based on this examination, is the patient medically capable of:
▪ safely operating a motor vehicle?
▪ safely operating a motorcycle?
▪ safely operating a commercial motor vehicle includes tractor trailers, passenger
buses, tank vehicles, school buses for 16 or more occupants (including the
driver), or vehicles carrying hazardous materials?
YES NO
If you have questions or need more information to complete this page, call Medical Review Services (804) 367- 6203.
Is the patient's condition(s) stable? If No, explain.
NOYES
Is the patient compliant with treatment? If No, explain:
NOYES
Does the patient experience side effects of medications, which are likely to impair driving ability? If Yes, explain:
NOYES
to be retested by DMV on Knowledge Road Both
a driver evaluation (with a certified independent driver rehabilitation specialist CDRS).
an adaptive device/equipment required to safely operate a motor vehicle.
a prosthetic/orthotic device to operate a motor vehicle
Problem Solving and Decision Making Cognitive Function
Emotional or Behavioral Stability Reaction Time
Strength and Endurance Maneuvering Skills
Range of Motion Use of Arm(s) and/or Leg(s)
ADDITIONAL RECOMMENDED RESTRICTIONS MEDICATIONS
PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER NAME (print)
MEDICAL SPECIALTY
MEDICAL LICENSE NUMBER EXPIRATION DATE (mm/dd/yyyy) ISSUING STATE
PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER SIGNATURE
DATE (mm/dd/yyyy)
TELEPHONE NUMBER FAX NUMBER
YES NO
YES NO
Based on this examination, the patient's driving ability is likely to be impaired by limitations in the following areas: (check each appropriate item)
Judgment and Insight Sensorimotor Function
Based on this examination, patient needs the following: (check each appropriate item)
For clarification on any of the above, contact Medical Review Services at 804 367-6203.
Based on this examination, is the patient medically capable of:
▪ safely operating a motor vehicle?
▪ safely operating a motorcycle?
▪ safely operating a commercial motor vehicle includes tractor trailers, passenger
buses, tank vehicles, school buses for 16 or more occupants (including the
driver), or vehicles carrying hazardous materials?
YES NO
If you have questions or need more information to complete this page, call Medical Review Services (804) 367- 6203.
Is the patient's condition(s) stable? If No, explain.
NOYES
Is the patient compliant with treatment? If No, explain:
NOYES
Does the patient experience side effects of medications, which are likely to impair driving ability? If Yes, explain:
NOYES
to be retested by DMV on Knowledge Road Both
a driver evaluation (with a certified independent driver rehabilitation specialist CDRS).
an adaptive device/equipment required to safely operate a motor vehicle.
a prosthetic/orthotic device to operate a motor vehicle
Problem Solving and Decision Making Cognitive Function
Emotional or Behavioral Stability Reaction Time
Strength and Endurance Maneuvering Skills
Range of Motion Use of Arm(s) and/or Leg(s)
ADDITIONAL RECOMMENDED RESTRICTIONS MEDICATIONS
PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER NAME (print)
MEDICAL SPECIALTY
MEDICAL LICENSE NUMBER EXPIRATION DATE (mm/dd/yyyy) ISSUING STATE
PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER SIGNATURE
DATE (mm/dd/yyyy)
TELEPHONE NUMBER FAX NUMBER
YES NO
YES NO
FIRST MEDICAL PROVIDER
( )
( )
SECOND MEDICAL PROVIDER
( )
( )
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Med2 CUSTOMER MEDICAL REPORT (Virginia Department of Motor Vehicles)

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Completed 2 August 2020

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