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Medical Form for a School Pupil (7D) Driver
Certificate or a School Bus Driver Certificate
Registry of Motor Vehicles ● Vehicle Safety & Compliance Services
P.O. Box 55892 ● Boston MA 02205-5892
IMPORTANT: This application must be completed, signed, and dated. Incomplete applications will be returned.
A. Medical Information and Applicant Signature
I hereby authorize the Licensed Physician completing this form to discuss and release any or all medical records pertaining to content with/or to
representatives of the Registry of Motor Vehicles.
Applicant’s Signature ___________________________________________________________ Date ________________________
B. Patient Information Must be completed by a Licensed Physician, NOT a Nurse Practitioner or Physician Assistant.
Last Name First Name Middle Name Suffix
Date of Birth (MM/DD/YYYY) Driver’s License #
1. Is the applicant currently diagnosed with having diabetes? ...................................................................................................................
Yes
No
2. Does the applicant have an Implanted Cardiac Defibrillator? ..............................................................................................................
Yes
No
If “YES” the applicant must submit a “Cardiovascular Medical Evaluation Form” completed by a medical doctor.
3. Distant Visual Acuity (Snellen): Left eye: (OS)20/ ______________ Right eye: (OD) 20/ ____________
4. Hearing: Can the applicant perceive a forced whispered voice in the better ear at not less than five feet with or without
the use of a hearing aid or, if tested by use of an audiometric device, does not have an average hearing loss in the better
ear greater than 40 decibels at 500Hz, 1000 Hz, and 2000Hz with or without a hearing aid when the audiometric device
is calibrated to the American National Standard? .................................................................................................................................
Yes
No
5. Does the applicant have a Respiratory Disease/Disorder? ................................................................................................................
Yes
No
If “YES” does the applicant have an O2 saturation rate of greater than 88%, at rest or with minimal exertion,
with or without supplemental oxygen? ...................................................................................................................................................
Yes
No
6. Is the applicant currently diagnosed with Epilepsy? ...............................................................................................................................
Yes
No
7. Does the applicant have any loss or impairment of foot, leg, finger, hand, or arm likely to interfere with safe driving? .........................
Yes
No
8. Does the applicant have any other physical condition likely to interfere with safe driving? ......................................................................
Yes
No
9. Does the applicant have any mental, nervous, organic, or functional disease likely to interfere with safe driving? ............................
Yes
No
10. Does the applicant have any contagious or communicable diseases? ...............................................................................................
Yes
No
11. Is the applicant addicted to the use of narcotics, or habit-forming tranquilizers or stimulants, or the excessive
use of alcoholic beverages or liquors? ................................................................................................................................................
Yes
No
12. Please check ONE BOX below:
The patient named above IS medically qualified to operate a school pupil transport vehicle or a school bus and fulfill all of the
duties and responsibilities associated with such operation.
The patient named above IS NOT medically qualified to operate a school pupil transport vehicle or a school bus.
Is the applicant insulin dependent? ..............................................................................................................................................
Yes
No
Has applicant ever had a hypoglycemic episode or spell? ............................................................................................................
Yes
No
If “YES” to either above, the applicant must submit a “Diabetes Medical Evaluation Form”
completed by a Board Certified or Board eligible medical doctor in Endocrinology.
Does the applicant use
corrective lenses for driving?............................................................................................................. .......
Yes
No
Combined horizontal peripheral field of vision must be NOT LESS THAN 120 combined (Record in degrees.): ___________
Is
the applicant able to distinguish the colors red, green and amber? ...........................................................................................
Yes
No
(If applicant uses corrective lenses for driving, please specify visual acuity above as corrected with Rx)
