Form Mvd - 10124 - Medical Report - Motor Vehicle Division, State Of New Mexico
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MVD - 10124
State of New Mexico - Motor Vehicle Division
REV.
05/04
MEDICAL REPORT
DIVISION USE ONLY
❑ Permit
Please have this form completed by a physician and mail to:
License
❑ Regular
(or deliver to any New Mexico Motor Vehicle Field Office)
Medical Advisory Board
Type
❑ Commercial
❑ APPROVED
Issued:
MOTOR VEHICLE DIVISION
Drivers Services Bureau
❑ DENIED
Field Office No. ______________
P.O. Box 1028, Santa Fe, NM 87504-1028
Please be advised that the decision to allow applicant to continue to retain his/her New Mexico driver’s license is contingent upon the information provided in this medical
report. It is imperative, and in the best interest of the applicant and the motoring public, that all questions be answered and that the dates and results of any and all medical
examinations be provided. This report will be reviewed by a panel of physicians, become part of the applicant's record, is for the confidential use of the board or the division
and may not be divulged to any person or used as evidence in any trial.
ALL INFORMATION MUST BE TYPED OR PRINTED
1. Applicant's Name (Last, First, Middle Initial)
Date of Birth
2. Mailing Address
City/State/Zip Code
Social Security Number
3. DISEASE or CONDITION (explain below (#5) any box checked:
Neurological
Cardiovascular
Diabetes + Insulin Rx
Psychological
Stroke
Hypoglycemia
Epilepsy
Deafness
Orthopedic/Prosthetic
Loss of Consciousness
Eye Disorder
ESRD / Renal Dialysis
Dementia
Addiction(s)
Sleep Disorder
Other __________________________________
4. Physician: How long have you treated this patient?
Frequency?
Date of last examination?
5.
DIAGNOSES: (List)
TREATMENT: (Med/Surg/Device)
6. Disease or Condition Controlled?
YES
No
Driving Hazard?
YES
No
7. Tests on patient that affect medical opinion about driving:
______________
(name)
_____________
______________
______________
(results)
_____________
(results)
(results)
(results)
HgbA1C:
B.P.
ECG
Other:
_____________
______________
______________
(date)
(date)
(date)
_____________
(date)
8. From a MEDICAL standpoint only, is the patient capable of safe and competent driving?
YES
No
Comment if needed:
9. RESTRICTIONS
Daylight Only
Corrective Lenses
Oxygen
Local Area
Mechanical Aids
Prosthetic Aids
Outside Mirrors
Automatic Transmission
10. Indicate your recommended length for the interval to the next license renewal date
4 YEARS
1 YEAR
6 MONTHS
11. Physician's Name (Please PRINT NEATLY or TYPE)
Office Telephone Number
Office Address
City, State, Zip Code
Physician's Signature
Date Signed
(see reverse)
Physician License Number
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