Medical Report Form - Illinois Secretary Of The State Page 2
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1
2PATIENT’S NAME: ________________________________________________
5.
Current Status of Condition:
■ ■
■ ■
■ ■
(A) Controlled
(B) Not Controlled: will not affect driving
(C) Not Controlled Condition: may affect driving
(If Not Controlled is marked, you must provide details, which may include pertinent clinical information, i.e. test results, lab
values, etc.)
_______________________________________________________________________________________________________________
■ ■
■ ■
6.
In the past six months, has there been an attack of unconsciousness?
YES
NO
Date of Attack ______________________
(If YES, you must provide details, which may include pertinent clinical information.)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
■ ■
■ ■
7.
Have there been any attack(s) of unconsciousness since the original incident noted in Question 6?
YES
NO
Date of Attack(s) ______________ (If YES, you must provide details, which may include pertinent clinical information.)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
8.
If there has been an attack of unconsciousness in the past six months you may provide a recommended time frame to return
to driving. Please explain: ______________________________________________________________________________________
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
SECTION III MENTAL HEALTH — To be completed ONLY if driver has a Mental Health Disorder marked “YES” by MD/DO and/or Medical
Professional (NP/PA).
■ ■
■ ■
Mental Health Disorder: YES
NO
DATE OF COMPLETION OF MENTAL HEALTH SECTION III: _____________________________________
■ ■
■ ■
1.
In your professional opinion, is this individual MENTALLY FIT to safely operate a motor vehicle?
YES
NO
2.
Mental Health Disorder Diagnosis/Condition(s): _____________________________________________________________________
3.
List all current medications prescribed relating to mental health diagnosis/condition indicated above. (If medications are listed a
condition must be disclosed above in Question #2.) _______________________________________________________________
_______________________________________________________________________________________________________________
■ ■
4.
No medications prescribed
■ ■
■ ■
■ ■
5.
(A) Controlled
(B) Not Controlled: will not affect driving
(C) Not Controlled Condition: may affect driving
(If Not Controlled, you must provide details, which may include pertinent clinical information, i.e. test results, lab values, etc.)
_______________________________________________________________________________________________________________
SECTION IV — Additional information, special restrictions, etc.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
SECTION V — MD/DO and/or Medical Professional (NP/PA)
______________________________________________________
_______________________________________________________
Name of Medical Provider (Please Print)
Medical Provider’s Address (Please Print)
(
)
______________________________________________________
_______________________________________________________
Professional License Number/State License Issued
Telephone Number
(Unacceptable Signatures: Chiropractors, Residents, Fellows, Interns, RN’s, LPN’s, Co-signatures)
__________________________________________________________
___________________________________________________
■ ■
■ ■
■ ■
■ ■
Provider’s Signature — Date of Completion of Medical Health Section
MD
DO
NP
PA Provider’s Specialty
__________________________________________________________
___________________________________________________
■ ■
■ ■
■ ■
■ ■
Provider’s Signature — Date of Completion of Mental Health Section
MD
DO
NP
PA Provider’s Specialty
PLEASE MAINTAIN A COPY OF MEDICAL REPORT FOR YOUR RECORDS.
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