Form Dlab-Cdl-1 - Medical Report Form

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DLAB-CDL-1 REV 11/13
West Virginia Department of Transportation
Division of Motor Vehicles
Medical Report Form
PAGE 1
PART I •
TO BE COMPLETED BY THE DRIVER
(You must complete Part I before presenting the medical form to your doctor.)
A.) Patient Authorization
This medical report must re ect the results of the licensed physician's personal examination of the patient performed within 90 days of this
report being led. It must be signed by the patient authorizing the physician to release this report and any attachments to DMV.
PATIENT'S SIGNATURE
DATE
DRIVER’S LICENSE NUMBER
I hereby authorize the licensed physician completing and signing this medical
report to release such report to DMV along with any other medical information
(X)
necessary to determine my tness to operate a motor vehicle safely.
PATIENT'S NAME (Please Print)
(Last)
(First)
(Initial)
DATE OF BIRTH
DAYTIME TELEPHONE NUMBER
(
)
PATIENT'S ADDRESS
(Street)
(City)
(State)
(Zip Code)
EMAIL ADDRESS (Optional)
PART II •
TO BE COMPLETED BY THE EXAMINING PHYSICIAN
B.) Applicant’s Medical History •
This form must be signed by a licensed medical practitioner.
Has the applicant ever had any of the following illnesses or conditions?
1. How long has applicant been your patient?
If YES, you must complete the appropriate sections under PART III.
/
/
Date you last treated applicant before today: ______________
DIABETES MELLITUS
Yes
No
MUSCULOSKELETAL DISORDER
Yes
No
2. Names of other physicians who have treated applicant in the
EMOTIONAL OR MENTAL ILLNESS
Yes
No
past two years: _________________________________________
CARDIOVASCULAR DISORDER
Yes
No
ALCOHOL/DRUG PROBLEM
Yes
No
______________________________________________________
NEUROLOGICAL DISORDER
Yes
No
______________________________________________________
SLEEPING DISORDER
Yes
No
PART III •
TO BE COMPLETED BY THE EXAMINING PHYSICIAN
C.) Details on Applicant’s Conditions or Illnesses •
ONLY complete sections for questions answered with a YES under Section II.
| THIS SECTION MUST BE COMPLETED BY A BOARD CERTIFIED/ELIGIBLE ENDOCRINOLOGIST
A. DIABETES MELLITUS:
1. Age of onset:
Does applicant take insulin or oral diabetic medication?
If yes what kind and dosage?
Yes
No
________________________________________________________________________________________________________________
2. Has applicant ever been in diabetic coma or shock?
If yes, how many times? _________________________________
Yes
No
/ /
Date of last coma/shock: ______________
3. Has the applicant had insulin reactions severe enough to impair judgment or ability to drive a motor vehicle?
Yes
No
/ /
If yes, how many times? ________________________ Date of last episode: ______________ Explanation: _____________________
_____________________________________________________________________________________________________________
4. Does applicant have diabetic retinopathy?
5. Is applicant’s diabetic condition under adequate control?
Yes
Yes
No
No
B. MUSCULOSKELETAL DISORDER:
(Patient may be required to pass a Skilled Performance Evaluation (SPE))
1. What type of musculoskeletal disorder does applicant have? _______________________________________________________
2. Are there any spastic or paralyzed muscles?
If yes, brie y describe: ________________________________________
Yes
No
3. Has there been an amputation?
If yes, what portion of the anatomy?
Yes
No
4. Does applicant require any orthopedic appliance or supports?
If yes, what?
Yes
No

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