Form Dmv06-19 - Statement Of Physician
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1
2STATEMENT OF PHYSICIAN
NEBRASKA DEPARTMENT OF MOTOR VEHICLES
Once completed, please mail or fax to: PO Box 94726 Lincoln, NE 68509
FAX:
402-471-4020
NOT VALID AFTER 90 DAYS FROM EXAMINATION DATE
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
By this form, or copy thereof, I hereby authorize and request the examining doctor to provide any information regarding my
physical and psychological condition or history to the Department of Motor Vehicles, State of Nebraska.
Dated:
Signed:
(Applicant’s Signature)
I hereby certify that I examined
(Applicant’s Name)
of
(Street Address)
(City)
(Zip Code)
Date of Birth
License Number
NEUROLOGICAL AND NEUROMUSCULAR DISEASES/CONDITION/INJURY:
I. CONDITION CAUSING CONFUSION, MEMORY LOSS OR LOSS OF CONSCIOUSNESS (Check)
1.
Epilepsy-Type:
Narcolepsy
Alcoholism (complete Alcohol section below)
Cerebral Vascular Disease
Other:
2. Frequency of seizures:
Date of last seizure:
Reason for seizure___________________________________________________
3. Frequency of loss of consciousness:
Date of last occurrence of loss of consciousness:
Reason for loss of consciousness___________________________________________________
4. Current medication and dosage:
Have significant sedative or hypnotic effects occurred:
No
Yes
Explain_______________________
5. Is this condition likely to worsen in the near future affecting the person’s ability to operate a motor vehicle?
No
Yes
Explain:
II. OTHER LIMITING OR PROGRESSIVE NEUROLOGIC OR NEUROMUSCULAR DISEASES (CEREBRAL PALSY,
PARAPLEGIA, MUSCULAR DYSTROPHY, PARKINSONISM, STROKE, MULTIPLE SCLEROSIS, ETC.)
1. Specific diagnosis:
__________________________________ ____ Age at onset:___________________________
2. Significant deterioration of neuromuscular function (strength, coordination) in the past year? _____________________
3. Describe the patient’s neuromuscular functional limitations (strength, coordination, etc.):
CONDITION CAUSING VERTIGO OR MULTIPLE EPISODES OF DIZZINESS OR FAINTING:
1. Specific diagnosis:_________________________________________ Date of last occurrence:___________
2. Has condition been resolved?____________________________ Please explain:_____________________
DRUGS AND ALCOHOL EVALUATION:
1. Does the patient have or is there any objective evidence of addiction or habituation to drugs, tranquilizers or alcohol?
No
Yes
If yes, type of drug and duration_______________________________________
2. Is patient currently under therapy?
No
Yes Explain: _____________________________
3. Evidence of physical complications of alcohol or drugs (please state):
___________________
PSYCHOLOGICAL EVALUATION:
1. Diagnosis of psychiatric illness:
If any of the following symptoms are present please mark #1 or a #2
1. Does not impair ability to operate a motor vehicle.
2. Impairs ability to operate a motor vehicle.
(
) Anxiety
(
) Visual or auditory
(
) Impairment of judgment
(
) Delusions
(
) Suicidal impulses or behavior
(
) Impairment of memory
(
) Euphoria
(
) Homicidal impulses or behavior
(
) Daytime sleepiness
(
) Hallucinations
(
) Paranoid ideation
(
) Other:
(
) Intermittent Explosive Episodes
(
) Depression
Page 1 of
TSIE5 07/12 DMV06-19
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