Form 1528 - Physician'S Statement

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MISSOURI DEPARTMENT OF REVENUE
DRIVER LICENSE BUREAU, P.O. BOX 200
TELEPHONE: (573) 751-2730
FORM
301 WEST HIGH STREET, ROOM 470
FAX: (573) 522-8174
1528
JEFFERSON CITY, MO 65105-0200
WEB SITE:
PHYSICIAN’S STATEMENT
(REV. 10-2012)
PATIENT NAME (LAST, FIRST, MIDDLE)
SOCIAL SECURITY NUMBER
DATE OF BIRTH (MM/DD/YYYY)
DRIVER OR
__ __ __ - __ __ - __ __ __ __
__ __ / __ __ / __ __ __ __
PATIENT
PATIENT’S MAILING ADDRESS
CITY
STATE
ZIP CODE
SECTION
__ __ __ __ __
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?
Yes
No
Ride with Family Member or Friend
3. What is the one-way distance of your furthest regular trip?
_____________ miles
Walk or Ride a Bicycle
4. Do any of your regular trips involve speeds > 55 MPH?
Yes
No
Public Bus, Van or Train
5. Were you pulled over by a police officer in the past year?
Yes
No
Private Bus, Van or Taxi
6. Were you involved in a crash as a driver in the past year?
Yes
No
Other _________________________
Pursuant to Section 302.291 RSMo, completing this report does not violate physician or patient privilege,
PHYSICIAN
and when in good faith, the physician shall be immune from any civil liability that might otherwise result
SECTION
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.
Cardiovascular Disease
Yes
No
Are you a regular or primary care provider for this patient?
Yes
No
Cardiac Arrhythmia
Yes
No
If yes, how many times have you seen this patient in the past year? _________
Heart Failure
Yes
No
If no, are you evaluating this patient for the first time today?
Yes
No
History of MI
Yes
No
History of Syncope
Yes
No
If no, have you reviewed the patients medical records?
Yes
No
To your knowledge, is this patient:
AHA Functional Capacity
Aware of his or her medical diagnosis & status?
(circle level if applicable)
Yes
Somewhat
No
I
II
III
IV
Aware of functional impairments that may impact driving?
Distance Acuity
LEFT
RIGHT
BOTH
Yes
Somewhat
No
Compliant with medications & basic requirements of self-care?
With Correction
20/
20/
20/
Yes
Somewhat
No
W/O Correction
20/
20/
20/
VISION & HEARING
o
Field Width
Macular Degeneration
Glaucoma
Cataracts
Date (MM/DD/YYYY)
Phone
Field Deficit on Confronation
Retinopathy
Other Vision ______________
__ __ / __ __ / __ __ __ __
( __ __ __) __ __ __ - __ __ __ __
Licensed Physician Name (printed)
Significant Hearing Loss (for commercial drivers only)
Should patient be required to wear glasses or lenses while driving?
Yes
No
Signature (required)
Should patient be restricted to daylight driving?
Yes
No
License #
Does patient have visual field deficit which makes driving unsafe?
Yes
No
DOR-1528 (10-2012)
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