Medical Report Form - Illinois Secretary Of State
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1
2DRIVER ANALYSIS DIVISION
Office of the Secretar y of State
2701 S. DIRKSEN PARKWAY
SPRINGFIELD, IL 62723
217-782-7246
Driver Ser vices Depar tment
Medical Report
Pursuant to Section 6-908 of the Driver's License Medical Review Law of 1992 and 625 Illinois Compiled Statutes 5/2-123(j), all
medical statements or reports received by the Secretary of State shall be confidential. This information will be disclosed only as
authorized by the above referenced statutes as now or hereafter amended.
To be Completed by Individual
(Please print or type)
Pursuant to Section 1030.16 of the Illinois Administrative Code, please complete the following information and sign the medical
agreement as a condition of licensure (92 Ill. Adm. Code 1030.16).
Name ______________________________________________________ Driver’s License Number ____________________________
Last
First
Middle
Street Address ________________________________________ Date of Birth ______________________ Sex ❍ Male ❍ Female
Mo.
Day
Year
City ____________________________________________ County _____________________________ ZIP Code ________________
Agreement
I agree to remain under the care of my physician and follow treatment exactly as prescribed. I also authorize my physician to report any
change in my condition that would impair my ability to safely operate a motor vehicle. I understand that failure to abide by the
conditions set forth in this agreement are grounds for the Secretary of State to deny or cancel my driving privileges. This report shall
remain valid for three months.
__________________________________________________
__________________________________________________
Signature of Individual
Date
To be Completed by a Medical Specialist
Medical Condition
Yes ❍
No ❍
1.
In your professional opinion, is this individual medically fit to safely operate a motor vehicle?
2.
Does this individual have:
Yes ❍
No ❍
Yes ❍
No ❍
(a) Any Cardiovascular Disease?
(f) Musculoskeletal Condition?
Yes ❍
No ❍
Yes ❍
No ❍
(b) Dizzy or Fainting Spells?
(g) Alcohol/Drug Abuse?
Yes ❍
No ❍
Yes ❍
No ❍
(c) Seizure Disorder?
(h) Mental Disorder?
Yes ❍
No ❍
Yes ❍
No ❍
(d) Other Neurological Disorder?
(i)
Respiratory Condition?
Yes ❍
No ❍
(e) Diabetes?
(j)
Other ____________________________________________
_____________________________________________________
(continued on back)
Printed by authority of the State of Illinois - October 2006 - 100M - DSD DC-163.4
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