Medical Report Form - Illinois Secretary Of The State
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DRIVER ANALYSIS DIVISION
Office of the Secretar y of State
2701 S. DIRKSEN PARKWAY
SPRINGFIELD, IL 62723
217-782-7246
Driver Ser vices Depar tment
Medical Report
Per 625 ILCS 5/6-908 of the Driver’s License Medical Review Law and 625 ILCS 5/2-123(j), all medical statements or reports received by
the Secretary of State shall be confidential. This information will be disclosed only as authorized by the above-referenced statutes as now
or hereafter amended.
SECTION I — To be Completed by Driver (Please print or type)
Pursuant to 92 Illinois Administrative Code 1030.16, please complete the following information and sign the medical agreement as a condition
of licensure.
Name ___________________________________________________
Driver’s License Number _________________________________
Last
First
Middle
■ ■
■ ■
Street Address ________________________________________ Date of Birth _______________________ Gender
Male
Female
Month
Day
Year
City ________________________________________________________________________ ZIP Code ________________________
Agreement/Release of Information
I agree to remain under the care of my physician and follow the treatment exactly as prescribed. I hereby authorize and request my physician
to release information regarding my medical condition to the Illinois Secretary of State, and to report any change in the status of my condition
that would impair my ability to safely operate a motor vehicle. I understand that failure to abide by the conditions set forth in this agreement
are grounds for the Secretary of State to deny or cancel my driving privileges. This report shall remain valid for three months (90 days).
__________________________________________________
__________________________________________________
Signature of Individual
Date of Signature
SECTION II MEDICAL HEALTH — To be Completed by MD/DO and/or Medical Professional (NP/PA)
Per Illinois Administrative Code Title 92, Part 1030, all sections of this report must be completed in its entirety.
DATE OF COMPLETION OF MEDICAL HEALTH SECTION II: _____________________________________
■ ■
■ ■
1.
In your professional opinion, is this individual MEDICALLY FIT to safely operate a motor vehicle?
YES
NO
2.
Conditions: Yes or No required for each condition listed.
■ ■
■ ■
(a) Cardiovascular
YES
NO
(provide condition)_______________________________________________
■ ■
■ ■
(b) Neurological
YES
NO
(provide condition)_______________________________________________
■ ■
■ ■
(c) Musculoskeletal
YES
NO
(provide condition)_______________________________________________
■ ■
■ ■
(d) Respiratory
YES
NO
(provide condition)_______________________________________________
■ ■
■ ■
(e) Seizure
YES
NO
(provide condition)_______________________________________________
■ ■
■ ■
(f) Diabetes
YES
NO
■ ■
■ ■
(g) Dizzy/Fainting Spell
YES
NO
■ ■
■ ■
(h) Alcohol/Drug Abuse
YES
NO
(i) Other Medical Condition(s)
(provide condition)_______________________________________________
*For mental health disorders, please refer to Section III-Mental Health. Section III must be completed if the individual has a
MENTAL HEALTH disorder.
3.
List all current medications prescribed relating to any condition indicated above in Question #2. (If medications are listed a
condition must be disclosed above in Question #2.) _______________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
■ ■
4.
No medications prescribed
(continued on back)
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