Form Dmv06-19 - Statement Of Physician Page 2
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1
2MEDICAL EVALUATION:
I. DIABETES
Type:
Adult Onset
Juvenile Onset
Duration:
Insulin:
No
Yes
Dose:
___________________________
Oral hypoglycemic agents .........................
No
Yes
Dose:
Hypoglycemic reactions ............................
No
Yes
Frequency:
Date of last reaction:_______________________
Renal Disease ...........................................
No
Yes
BUN_________ Creatinine__________________
Retinopathy ...............................................
No
Yes
Should statement on vision be required? ..
No
Yes
II. ARTERIOSCLEROSIS
Peripheral vascular disease ......................
No
Yes *
Cerebral vascular disease .........................
No
Yes *
* If yes, please complete Section III, HEART DISEASE.
Coronary vascular disease ........................
No
Yes *
III. HEART DISEASE
Diagnosis:
Angina:
No
Yes
Frequency:
Date of Onset:
During Driving:
No
Yes
Lightheadedness:
No
Yes
Syncope:
No
Yes
Arrhythmia:
No
Yes
Type:
Frequency:
Infarction:
No
Yes
Number and dates:
Congestive failure at present:
No
Yes
Ever:
No
Yes
Pacemaker:
No
Yes
Blood Pressure:
Heart Rate:
GENERAL STATEMENTS (THIS SECTION MUST BE COMPLETED IN ITS ENTIRETY):
1
In your professional opinion, is this patient mentally capable of operating a motor vehicle safely?
No
Yes
Only if appropriate tests as determined by the DMV are passed .
2.
In your professional opinion, is this patient physically capable of operating a motor vehicle safely?
No
Yes
Only if appropriate tests as determined by the DMV are passed .
3. Do you feel that this patient should have a medical evaluation for the purpose of operating a motor vehicle safely?
No
Yes
If yes, how often?
If you wish to make additional comments, such as driving distance or day or night driving, or you have any recommended
restrictions patient should have on license, please use space below or additional sheet(s) as necessary.
If there are any other medical conditions not shown on this report that would affect the patient’s ability to safely operate a
motor vehicle, please describe as to frequency, severity, etc.:
4.
Based upon your examination, has the medical condition of this patient significantly worsened or another condition
developed?
No
Yes
If yes, please explain including how this affects the person’s ability to safely operate a motor
vehicle.
For Commercial Motor Vehicle Operators Only: Was this condition in existence prior to July 30, 1996?
No
Yes
DATE OF EXAMINATION:
(MUST BE COMPLETED—STATEMENT OF PHYSICIAN
NOT VALID 90 DAYS FROM EXAMINATION DATE.)
Name (Print or Type)
M.D. or D.O.
Type of Practice
Signature
Address
Phone Number:_________________________________
Fax Number:__________________________________
TSIE5 07/12
Page 2 of 2
DMV0-191
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