Driving Licence Medical Report Form - Ndls Page 2
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2Driving Licence Medical Report Form
To be completed by a Medical Practitioner whose name is on the General Register of Medical Practitioners in Ireland.
I, the undersigned registered medical practitioner report that:
• The applicant has signed the declaration in my presence
• I have examined the applicant by reference to the medical fitness standards required by the Road Traffic Acts and in my
opinion, the applicant. (Please X the appropriate box(es) below):
Group 1. Meets the prescribed medical fitness standard set out for vehicles in Group 1.
Yes
No
If the answer to the above is Yes indicate the licence period recommended for this driver by marking the below:
1 year
3 years
10 years
Group 2. Meets the prescribed medical fitness standard set out for vehicles in Group 2.
Yes
No
N/A
If the answer to the above is Yes indicate the licence period recommended for this driver by marking the below:
1 year
3 years
5 years
(N.B. A person driving a Group 2 category vehicle must be certified as medically fit at least every five years).
Exceptional case Epilepsy. (available to Group one drivers only)
If your patient has indicated that his/her last seizure was less than 12 months ago (see page 1) and you consider him/her fit to
drive, please indicate that this is because the seizure was one of the following:-
1. first seizure; provoked seizure only in preceding year; seizure not affecting consciousness or driving ability;
seizure in preceding year only on withdrawal of antiepileptic medication; or seizure exclusively while asleep
and the first such sleep seizure was a minimum of 12 months previous
and
2. that the driver has been assessed as fit to drive by a consultant neurologist.
The applicant needs to wear corrective lenses while driving.
Yes
No
The applicant has a physical disability requiring adaptations be made to a vehicle
to meet the requirements of their disability.
Yes
No
The applicant has had a limb prosthesis/orthesis.
Yes
No
My opinion as to (INSERT APPLICANTS NAME IN BLOCK CAPITALS) __________________________________________________
medical fitness is that he/she is fit to drive vehicles of the Group indicated from any date up to one month
from today’s date.
Date of Examination:
Signature
Day
Month
Year
Stamp of Medical Practitioner whose name is on the
General Register of Medical Practitioners in Ireland
Medical Practitioner's Details
Name:
Address:
Telephone:
Email address:
Fax:
EXPLANATORY NOTES
1. To complete your medical examination you must go to your doctor, have your medical examination and sign this form in the presence of the doctor. When
the form is completed by your doctor you must send it to National Driver Licence Service with your learner permit/driving licence application within one
month of the date of the medical examination.
2. For medical fitness standards vehicles are classed as being in Group 1 or Group 2. The graphic overleaf describes which vehicles are in Group 1 and in Group 2.
Further information on each licence category can be found on the licence application form. A higher standard of medical fitness is required of those drivers
who hold licences for Group 2 vehicles. Please note that Group standards apply to all categories of vehicles within that Group. Individual categories
should not be marked on the table overleaf.
3. A person driving a Group 2 category vehicle must be certified as medically fit at least every five years.
4. Applicants over 70 years of age can only be certified as being fit to drive for either one or three years.
5. Where appropriate the doctor may engage the services of other medical and driving professionals (e.g. consultant, occupational therapist, optometrist,
on-road driving assessor) to inform their completion of this form.
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