Patient Name: _______________________________________ Last 4 Social: __________
p.2 MAB106_1018
4. If condition involves seizure or any type of altered or loss of consciousness, please state type and date of last
episode(s).
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5. Is patient on any medication(s)? ..................................................................................................................
Yes
No
If yes, list medication(s) with dosage(s): _______________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Are these medications, separately or in combination, likely to interfere with the patient’s ability to operate a motor
vehicle safely? ..............................................................................................................................................
Yes
No
6. Please check one of the following categories:
I hereby certify that in my professional opinion and to a reasonable degree of medical certainty, one of the following:
The patient named above is medically qualified to operate a motor vehicle safely.
The patient named above is NOT medically qualified to operate a motor vehicle safely.
The patient may require adaptive equipment and/or an assessment for appropriate license restrictions via a
competency road examination.
I am unable to determine driving ability and recommend the patient undergo a competency road examination.
7. Please check one:
I have read the attached police report and am aware of the reported incident involving
my patient. .....................................................................................................................................
Yes
No
N/A
Additional comments: ______________________________________________________________________________
________________________________________________________________________________________________________
B. Physician Certification
Physician’s Name
National Provider Number (NPI #)
Massachusetts Board of Registration #
Address
Street City State
Zip
Code
I hereby certify, under the pains and penalties of perjury, that the information I have provided herein is true,
accurate and complete.
Certifying Physician’s Signature: __________________________________________ Date: ___________________
Classification Guidelines:
AMERICAN ASSOCIATION FUNCTI ONAL CLASSIFICATION SYSTEM
CLASS I Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not
cause fatigue, palpitation, dyspnea, or anginal pain.
CLASS II Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary
physical activity result in fatigue, palpitation, dyspnea, or anginal pain.
CLASS III Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less
than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.
CLASS IV Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of
cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken,
discomfort is increased
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