Form Co/dv-124 - Driver Medical History Form Page 3
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3DL#: ______________________
C.
NEUROLOGICAL EVALUATION
Is there any evidence of a Seizure / Syncope Event / Blackout / Dizzy Spell Disorder? If “YES”,
Check One:
please provide:
YES ☐
NO ☐
DAY ☐
NIGHT ☐
1.
Type of Seizure / Syncope Event / Blackout / Dizzy Spell Disorder:
_____________________________________________________________________________
Date of Last Seizure / Syncope Event / Blackout / Dizzy Spell / Loss or Alteration of
Consciousness:
_____________________________________________________________________________
Frequency:________________________
Medication(s):__________________________________________________________________
EEG Report
Date of
Result:_______________________________________________________________________
Report:___________________________
2.
Other Neurological Impairment(s)::
Diagnosis:____________________________________________________________________
Progressive?__________________________________________________________________
Prognosis:________________________
Medication(s):_________________________________________________________________
Check One:
YES ☐
NO ☐
Any Loss or Alteration of Consciousness:
Date / Frequency of Last Loss / Alteration of Consciousness:____________________________
SECTION IV: PHYSICIAN'S CERTIFICATION
Description of Limitation(s). Include any effect this impairment may have on the patient’s ability to safely operate a motor vehicle:
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Recommendations / Restrictions to be placed on the License if issued:
(Limit 6)
☐ Corrective Lenses
☐ Within City Limits
☐ Outside Mirror
☐ Daylight Hours Only
☐ Licensed Driver In Front Seat
☐ Automatic Transmission
☐ No Interstate / Freeway Driving
☐ Mechanical Aid
☐ ( ___ )Miles From Home
☐ Outside Business Area
☐ Prosthetic Aid
(5-30 in 5 mile increments)
Check One:
YES ☐
NO ☐
Driver must take and pass a drive test at a Kansas Exam Station.
YES ☐
NO ☐
Annual Medical Report should be required.
YES ☐
NA ☐
NO ☐
Driver is reliable in taking medications?
YES ☐
NA ☐
NO ☐
Driver’s medical condition is controlled?
Driver has been under my care for how long? _____________________________________________________________________________
In my professional opinion, I believe this person can safely operate a motor vehicle at this time in
Check One:
regards to their physical / mental state. (Driver must be considered a safe candidate in order to
YES ☐
NO ☐
request a drive test.)
(Within the last 90 days)
Name of Physician:_______________________________________________________
Exam Date:_________________________________
Physician License#:_______________________________________________________
Specialty:____________________________________
Physician Address:_______________________________________________________
Phone#:_____________________________________
Other comments / recommendations to be considered regarding this driver’s medical condition as it relates to his / her driving privileges:
______________________________________________________________________________________________________________________
Supervising Physician Signature:___________________________________________________________
Date:__________________________
CO/DV-124 (Rev 03/15)
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