Driver'S Medical Examination Report - Nova Scotia Page 2
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1
2Driver’s Medical Examination Report
Name:
Driver’s Master No.:
____________________________________________________________________________________________
__________________________________________________________________________
Part 3: Examination Report – continued – Check Nothing to Report or check and complete applicable conditions(s)
m
m
C – RESPIRATORY
NotHING to rePort
D – RENAL DISEASE
NotHING to rePort
q
q
1. respiratory Impairment
1. Dialysis
m
m
m
Mild
Moderate
severe
q
2. transplant: Date
___________________________________________________________________
q
2. supplemental oxygen
q
3. Nephropathy
m
m
occasional
continuous
m
m
E – METABOLIC
F – SUBSTANCE USE/ABUSE
NotHING to rePort
NotHING to rePort
q
q
1. Diabetes. treated by:
1. Alcohol Abuse
m
m
m
Diet
oral Medication
Insulin
m
Under control since:
_____________________________________________________
m
m
Well controlled
Not well controlled
m
Not controlled
q
q
2. severe Hypoglycemia :
2. Alcohol related seizure: Date
_________________________________________________
Date of last episode
q
______________________________________________________________
3. Drug Abuse
q
3. Hypoglycemia Unawareness:
m
substance:
_____________________________________________________________________
Date of last episode
______________________________________________________________
m
Under control
q
4. complications related to Diabetes
m
Not controlled
m
m
Peripheral Vascular
retinopathy
q
4. Prescribed medication that could cause impairment:
m
Neuropathy ____________________________________
__________________________________________________________________________________________
For all Commercial Drivers or Any Driver if not well controlled
__________________________________________________________________________________________
HbA1c Level:
Date
_________________________
_________________________________
blood Glucose:
Date
__________________________________________________________________________________________
_______________________
________________________________
( D D / M M / Y Y Y Y )
m
m
G – MUSCULOSKELETAL
NotHING to rePort
H – HEARING
NotHING to rePort
q
q
m
m
1. Amputation:
1. significant Hearing Loss. Corrected?
Yes
No
________________________________________________________________________
(classes 1 – 4 only)
q
2. Weakness:
Perceives a forced whispered voice at not less than 5 feet (1.5
___________________________________________________________________________
q
metres) with or without the use of a hearing aid or, hearing loss
3. Impaired range of motion:
______________________________________________________
no greater than 40dB averaged at 500, 1000, and 2000 Hz in
their better ear
______________________________________________________________________________________________________
m
m
I – PSYCHIATRIC
NotHING to rePort
J – OTHER CONDITIONS
NotHING to rePort
q
(that may affect driving)
1. Psychosis
q
q
1. General Debility
2. Personality Disorder
q
q
2. other
3. severe depression or anxiety
__________________________________________________________________________________
q
4. other:
_________________________________________________________________________________
Part 4: Opinion and Recommendations
m
PHYSICIAN’S STAMP
ISSUE LICENCE AS APPLIED FOR
or:
q
1. Issue licence with restrictions:
_______________________________________________
__________________________________________________________________________________________
q
2. road test required
q
3. suspend licence pending:
______________________________________________________
q
4. suspend – unlikely to improve
Part 5: Medical Professional Details
q
Name:
family Physician
____________________________________________________________________________________________
q
m
m
Address
Walk in or Locum Chart Reviewed
Yes
No
__________________________________________________________________________________________
q
Postal code:
specialist
________________________________________________________
_______________________
q
PHoNe (
)
fAX (
)
Nurse Practitioner
_____________________________________
__________________________
________________________________________________________
_________________________________________
sIGNAtUre
DAte (DD/MM/YYYY)
Page 2 of 2
novascotia.ca/snsmr/rmv/licence
As of october 2014
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