MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU, P.O. BOX 200
TELEPHONE: (573) 751-2730
301 WEST HIGH STREET, ROOM 470
FAX: (573) 522-8174
JEFFERSON CITY, MO 65105-0200
PATIENT NAME (LAST, FIRST, MIDDLE)
SOCIAL SECURITY NUMBER
DATE OF BIRTH (MM/DD/YYYY)
__ __ __ - __ __ - __ __ __ __
__ __ / __ __ / __ __ __ __
PATIENT’S MAILING ADDRESS
__ __ __ __ __
I hereby authorize and accept that:
• My physician will conduct a medical examination to determine my fitness to operate a motor vehicle safely and responsibly.
• My physician will respond to any additional questions from the Driver License Bureau (DLB) and, if necessary, he or she
may submit copies of my medical records to the DLB.
• The DLB will make a final decision concerning my eligibility for driver licensure based on all available information.
Signature of Driver or Patient _______________________________________________________ Date (MM/DD/YYYY) __________________________
DRIVER AND PATIENT (respond to all questions below before seeing your physician)
7. In addition to driving, what other
modes of transportation do you use
1. How many driving trips do you make in a typical week?
regularly? (check all that apply)
2. Do any of your regular trips involve driving at night?
Ride with Family Member or Friend
3. What is the one-way distance of your furthest regular trip?
Walk or Ride a Bicycle
4. Do any of your regular trips involve speeds > 55 MPH?
Public Bus, Van or Train
5. Were you pulled over by a police officer in the past year?
Private Bus, Van or Taxi
6. Were you involved in a crash as a driver in the past year?
Pursuant to Section 302.291 RSMo, completing this report does not violate physician or patient privilege,
and when in good faith, the physician shall be immune from any civil liability that might otherwise result
from making this report. INSTRUCTIONS: Use your best clinical judgement as you REVIEW AND
COMPLETE ALL SECTIONS. Attach additional sheets as necessary. Base severity ratings within each category on your overall
assessment of impairment relative to the driving task.
EXAMINATION DATE (MM/DD/YYYY): ____________________________
Does this patient have:
Supplemental page(s) attached.
Are you a regular or primary care provider for this patient?
If yes, how many times have you seen this patient in the past year? _________
If no, are you evaluating this patient for the first time today?
History of MI
History of Syncope
If no, have you reviewed the patients medical records?
To your knowledge, is this patient:
AHA Functional Capacity
Aware of his or her medical diagnosis & status?
(circle level if applicable)
Aware of functional impairments that may impact driving?
Compliant with medications & basic requirements of self-care?
VISION & HEARING
Field Deficit on Confronation
Other Vision ______________
__ __ / __ __ / __ __ __ __
( __ __ __) __ __ __ - __ __ __ __
Licensed Physician Name (printed)
Significant Hearing Loss (for commercial drivers only)
Should patient be required to wear glasses or lenses while driving?
Should patient be restricted to daylight driving?
Does patient have visual field deficit which makes driving unsafe?
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