Form 1528 - Physician'S Statement Page 2
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1
2CURRENT MEDICATIONS
(check all that apply)
To your knowledge, is this patient subject to any
Sedative
CNS Stimulant
Antidepressant
Insulin
consistent side effects or interactions that may
Tranquilizer
Narcotic
Antihistamine
Digitalis
impair driving ability?
Anticonvulsant
Anticoagulant
Anti-Infective
Sleep Aid
Yes
Possibly
Not Likely
No
Other ______________________________________________________
COGNITIVE, CEREBROVASCULAR OR NEUROLOGICAL
Condition is:
Permanent
Temporary
Mental Status _____________________________
Cognitive Impairment
Cerebrovascular Disease
Neurological Condition
(list test and score)
Alzheimer’s Disease
Cerebral Infraction or Stroke
Brain Injury
(open or closed)
Confusion or Disorientation
Memory Loss or
Forgetfulness
Vascular Dementia
Hemorrhage or Aneurysm
Tumor or Malformation
Inattention or Distractibility
Impaired Judgement
Frontotemporal or Pick’s
Transient Ischemic Attack
Parkinson’s Disease
Carotid Occulsion or Hypozxia
Visual-Spatial Deficit
Slowed Processing Speed
Dementia
Multiple Sclerosis
(other or unknown)
Combined Impairment for Driving
UNIMPAIRED
VERY MILD
MILD
MODERATE
SEVERE
Likely Unfit to Drive
Likely Fit to Drive
Likely Fit to Drive
Questionable Fitness
Likely Unfit to Drive
Check (X) Highest Level for Section
CONSCIOUSNESS, METABOLIC OR RESPIRATORY
Condition is:
Permanent
Temporary
*DATE of last event with impaired consciousness (MM/DD/YYYY): ______________________
Disorder of Consciousness or Alertness*
Metabolic Condition
Respiratory Condition
Blackout or Syncope*
Sleep Apnea or Narcolepsy
Diabetes (Type 1 or 2)
Asthma or Shortness of Breath
Medication Effect
Chronic Sleep Deprivation
Thyroid Condition (Hypo or Hyper)
COPD
Epilepsy or Seizure Disorder
Dizziness or Postural Hypotension
Oxygen Dependent
Morbid Obesity or Fluid Retention
Combined Impairment for Driving
SEVERE
UNIMPAIRED
VERY MILD
MILD
MODERATE
Likely Fit to Drive
Likely Fit to Drive
Questionable Fitness
Likely Unfit to Drive
Likely Unfit to Drive
Check (X) Highest Level for Section
MUSCULOSKELETAL, MOVEMENT OR NEUROMUSCULAR
Condition is:
Permanent
Temporary
CHECK ALL THAT APPLY
Motor Neuron Disease
Muscular Dystrophy
Arthritis (Osteo or Rheumatoid)
Frailty or Generated Weakness
Multiple Sclerosis
Parkinson’s Disease
Uses Cane or Walker
Paralysis - Arm
Restricted or Weakness - Arm
Loss of Limb
Wheelchair Dependent
Paralysis - Leg
Restricted or Weakness - Leg
History of Falls
Difficulty Transferring
Prosthesis or Brace - Arm
Restricted Neck Range of Motion
Other __________________
Problems with Balance
Prosthesis or Brace - Leg
Orthopedic or Movement
__________________________
Combined Impairment for Driving
SEVERE
UNIMPAIRED
VERY MILD
MILD
MODERATE
Likely Unfit to Drive
Likely Fit to Drive
Likely Fit to Drive
Questionable Fitness
Likely Unfit to Drive
Check (X) Highest Level for Section
PSYCHIATRIC, EMOTIONAL OR ADDICTION
Condition is:
Permanent
Temporary
Psychosis or Schizophrenia
Depression
Bipolar Mood Disorder
Alcohol Abuse or Addiction
Drug Abuse or Addiction
Anxiety or Post-Traumatic Stress
Suicidal or Homicidal
Chronic Pain (causing distress)
Other___________________________
Combined Impairment for Driving
UNIMPAIRED
VERY MILD
MILD
MODERATE
SEVERE
Likely Unfit to Drive
Likely Fit to Drive
Likely Fit to Drive
Questionable Fitness
Likely Unfit to Drive
Check (X) Highest Level for Section
Based on my observations of this patient and information relayed to me by this individual, I, reasonably and in good faith, believe
P A T I E N T N A M E
that ______________________________________________________________________ is:
LIKELY CAPABLE of operating a motor vehicle safely and responsibly. There are no medical contraindications
MUST CHOOSE ONE
at this time. No further evaluation appears to be needed.
Recommended license restriction(s):
UNCLEAR IF CAPABLE of operating a motor vehicle safely and responsibly due to current medical-functional
Daylight Driving Only
status. I recommend additional evaluations to include:
No Highway Driving
Driving Skills Examination
Evaluation by Vision Specialist
Outside Rearview Mirror
Written Examination
Evaluation by Specialist ___________________________________
Special Hand Device
NOT CAPABLE of operating a motor vehicle safely and responsibly due to significant medical-functional
25 Mile Radius Only
compromise or deficit.
Restricted 25 MPH
SPECIALTY
LICENSE NUMBER
PHONE
Restricted 45 MPH
(
)
-
Specialty Cushion
__ __ __
__ __ __
__ __ __ __ __
OFFICE MAILING ADDRESS (INCLUDING ZIP CODE)
Special Foot Device
Other ____________________________
PHYSICIAN NAME (PRINTED)
SIGNATURE (REQUIRED)
DATE (MM/DD/YYYY)
/
/
__ __
__ __
__ __ __ __
DOR-1528 (10-2012)
PAGE 2 OF 2
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