Form 20-1900 - Driver Medical Evaluation - Montana Department Of Justice Page 2
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2Would the side effects from the prescribed medication interfere with the safe operation of a motor vehicle?
Yes
No
If yes, please describe:
D. LAPSE OF CONSCIOUSNESS DISORDER
Please identify any disease or disorder including epilepsy, narcolepsy, diabetes, cerebral vascular disease, or any other impairment that may
cause loss of consciousness or control of motor functions at any time.
Date of last episode
Is condition stabilized?
Yes
No
E. IMPAIRMENTS THAT ARE PRESENTLY SHOWN BY YOUR PATIENT
Sporadic loss of conscious awareness
Diminished judgment
Loss of consciousness
Memory loss
Impaired motor function
Alzheimer’s disease
Reaction, or impairment due to change in medication or dosage
Confusion
Neurological or neuromuscular disease
Other dementia
Diminished concentration
Other metabolic disorder
Comments:
F. IN YOUR OPINION, WOULD THE PATIENT’S PHYSICAL OR MENTAL CONDITION
Yes
No
INTERFERE WITH THE PATIENT’S SAFE OPERATION OF A MOTOR VEHICLE?
If yes, please describe:
1. Do you recommend any driving restriction or adaptive equipment that should be utilized to assist
your patient?
If yes, please describe:
2. Do you recommend the Motor Vehicle Division conduct periodic driving evaluation or have patient
submit periodic medical reports to monitor changes?
If so, how often?
G. PHYSICIAN
PHYSICIAN’S SIGNATURE
PHYSICIAN’S NAME (PRINTED)
DATE
TYPE OF PRACTICE OR MEDICAL
ADDRESS
TELEPHONE NUMBER
SPECIALTY
Please return completed form to:
Motor Vehicle Division
Att: Medical Unit
PO Box 201430
Helena Mt
59620-1430
20-1900 12/97
Supplemental Medical Statement
(Internet Version)
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