Form Mv346-Physicians Findings Form

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STATE OF DELAWARE
DEPARTMENT OF TRANSPORTATION
DIVISION OF MOTOR VEHICLES
DRIVER IMPROVEMENT UNIT - MEDICAL RECORDS SECTION
PO BOX 698
-
DOVER, DE 19903-0698
MEDICAL REPORT OF PHYSICIAN’S FINDINGS
Name: _____________________________________
DOB ___/___/___ License Number: ________________
Address: ___________________________________________________________________________________
I hereby authorize Doctor ___________________________________ to perform any medical examination
necessary for the purpose of determining my fitness to operate a motor vehicle.
Also I understand that this
authorization includes permission for the Director of Motor Vehicles and/or their designee to have this information
reviewed by a Medical Board of unidentified physicians for the purpose of giving him/her a medical opinion on my
case for a guidance in determining my medical capabilities to operate a motor vehicle safely. The information
contained in this report is confidential and will be used solely for the purpose of drivers license considerations.
_____________________________________
____________________________________________________
Date
Signature of Applicant (Required)
(Legibility is a must)
Mental level for reading (check one)
Inadequate
Marginal
Adequate Height: _________ Weight __________
(A)
ORTHOPEDIC AND NEUROMUSCULAR: (Please check as appropriate)
Spastic, Amputations or Ankylosed Joints
YES
NO
Joint Ataxia, Paralysis, or Weakness
YES
NO
Prosthetic Devices used for Driving
YES
NO
Other Deformities or Abnormalities
YES
NO
If YES to any of the above, please describe: _______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(B)
CARDIO-VASCULAR: (Please check as appropriate)
Strokes - Adams Syndrome
YES
NO Syncope
YES
NO
Vertigos
YES
NO
Angina Pectoris
YES
NO Arteriosclerosis
YES
NO
Arrhythmia
YES
NO
Cardiac Decompensation
YES
NO Dyspnea
YES
NO
Blood Pressure ____________
If YES to any of the above, please describe: _______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(C)
DIABETES: (Please check as appropriate)
Is he/she a known diabetic?
YES
NO
Status of Control ______________________________________
Duration: ____________________________
Diabetic Acidosis
YES
NO ________________________
If YES to any of the above, please describe: _______________________________________________________
___________________________________________________________________________________________
___________________________________________________________________________________________
(D)
HEARING: Normal?
YES
NO If NO, please describe: _________________________________
___________________________________________________________________________________________
(E)
DRUGS AND/OR ALCOHOL: (Please check as appropriate)
Any objective evidence or personal knowledge of addiction, habituation, or alcoholism?
YES
NO
If YES, please explain: ________________________________________________________________________
___________________________________________________________________________________________

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