Form Co/dv-124 - Driver Medical History Form Page 2
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3DL#: ______________________
SECTION III: PHYSICIAN'S REPORT
TO THE PHYSICIAN: Please complete the sections of this report applicable to this patient’s diagnosis and add comments related to any questions
marked "YES" by the patient in Section II. The physician assumes no liability. See Kansas Statute Section 8-247 (d) (6).
•
If you are not a Psychologist, Psychiatrist or a Neurologist you must complete Section A and IV.
•
If you are a Psychologist or Psychiatrist you must complete Section B and IV.
•
If you are a Neurologist you must complete Section C and IV.
A.
PHYSICAL EXAMINATION
1.
Other Physical Impairment(s) e.g. Diseases / Ailments / Complications
Description: ________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Diagnosis: _________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Prognosis: _________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Medication: ________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
B.
PSYCHOLOGICAL EVALUATION
Is there any evidence of any Psychological Dysfunction? E.G. Excessive Tension / Anxiety / Depression
Check One:
Hostility / Behavior Disorders / Paranoia / Suicidal Tendencies / Impairment of Judgment / Developmental or
YES ☐
NO ☐
Delayed Disability / Hallucinations / Delusions
If “YES”, please provide:
Diagnosis: ______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Prognosis: ______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Treatment: _____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Medications: ____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Check One:
YES ☐
NO ☐
ALCOHOL/DRUG DEPENDENCE?
If “YES”, please provide:
Diagnosis: ______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Prognosis: ______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Treatment: _____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
Medications: ____________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
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