Form Co/dv-124 - Driver Medical History Form
Download a blank fillable Form Co/dv-124 - Driver Medical History Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Form Co/dv-124 - Driver Medical History Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3PLEASE RETURN COMPLETED
STATE OF KANSAS DIRECTOR OF VEHICLES
MEDICAL FORMS TO:
DRIVER REVIEW SECTION
915 HARRISON STREET
PO BOX 2188
PH:
TOPEKA KS 66601-2188
FAX:
SECTION I: GENERAL DRIVER INFORMATION
Driver must complete Sections I and II.
Name: ________________________________________________________________
Date of Birth: ___________________________
___
Address:______________________________________________________________
Driver’s License Number: ___________________
Phone Number:________________________________________________________
☐
☐
Are you enrolled in Driver’s Education? YES
NO
Instructor’s Name:______________________________________________________
Instructor’s Phone #:____________________________
Permission is granted for release of all medical information concerning me to the Kansas Division of Vehicles and to all medical professionals who
complete any part of this form.
Dr.
Signature of Driver:
Date:
SECTION II: DRIVER MEDICAL HISTORY
If the answer to any of the following questions is “YES”, please give sufficient details in the remarks area at the end of this section.
Have you experienced or been treated for any of the following conditions within the past three (3) years:
Check One:
YES ☐
NO ☐
1.
Motor Vehicle Accident
YES ☐
NO ☐
2.
Driver’s License Revocation / Suspension / Cancellation
YES ☐
NO ☐
3.
Blackout Spells / Dizzy Spells / Epilepsy / Seizures / Loss or Alteration of Consciousness
Date of last episode:
YES ☐
NO ☐
4.
Other Neurological Impairments
YES ☐
NO ☐
5.
Head Trauma / Brain Surgery
YES ☐
NO ☐
6.
Nervousness
YES ☐
NO ☐
7.
Depression / Confusion / Other Psychiatric Disorders
YES ☐
NO ☐
8.
Memory Impairment
YES ☐
NO ☐
9.
Alcoholism
YES ☐
NO ☐
10.
Visual Impairment / Eye Disease
YES ☐
NO ☐
11.
Drug Abuse
YES ☐
NO ☐
12.
Hearing Impairment
YES ☐
NO ☐
13.
Amputations / Missing Extremities / Prosthesis
YES ☐
NO ☐
14.
Other Orthopedic Impairments
YES ☐
NO ☐
15.
High Blood Pressure
YES ☐
NO ☐
16.
Heart Disease / Cardiovascular Impairments
YES ☐
NO ☐
17.
Diabetes
YES ☐
NO ☐
18.
Other Diseases / Ailments/Complications: list below
Remarks: (Attach additional sheet if necessary)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal