Medical Report Form - Illinois Secretary Of State Page 2
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1
2Medical Condition (cont.)
3.
List medication(s) prescribed:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Yes ❍
No ❍
4.
Under current medical treatment regimen, is condition/disorder controlled?
Yes ❍
No ❍
5.
Have attacks of unconsciousness occurred within the past six months?
If yes, please provide the date(s) and detail(s):
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Mental Disorder
Yes ❍ No ❍
1.
In your professional opinion, is this individual mentally fit to safely operate a motor vehicle?
2.
Diagnosis: _______________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3.
Current Status Controlled/Stable,i.e.,: _________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4.
Is Medication/Treatment Prescribed? (Please Specify)
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Yes ❍
No ❍
5.
Has individual ever been hospitalized for treatment of the noted disorder?
Last Discharge Date:
Month:___________________ Year:___________
Comments: ______________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________
___________________________________________________
Physician’s Name (Please Print)
Physician’s Address (Please Print)
_______________________________________________
__________________________________________________
License Number
Date
_______________________________________________
___________________________________________________
Physician’s Signature
Telephone Number
Note: Must be signed by licensed medical specialist.
Printed by authority of the State of Illinois - October 2006 - 100M - DSD DC-163.4
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