Physicians Report - Mva Maryland Page 2
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4SECTION 2: HISTORY
In the past two years:
Yes
No
Unknown
Has your patient been in any vehicle crashes/accidents?
1.
1a. If YES, when?
2.
Has your patient expressed any concern(s) about their medical fitness to drive
Yes
No
Unknown
If YES, please explain:
3.
Has your patient had any of the following?
Loss of Consciousness (LOC)
Seizure
Syncope
Any LOC/altered state of consciousness requiring assistance
If YES, what was the date of the last episode?
Yes
No
Unknown
Has your patient sustained a fall?
4.
Have you treated this patient or referred him/her to another clinician for any of the following conditions that could
5.
affect driving? (Please use comment section to provide information.)
Yes
Date of Incident
Diabetes that has caused a low blood sugar episode requiring assistance from
another person in the last 6 months;
Epilepsy;
Seizure;
A heart condition that has caused a loss of consciousness in the past 6 months;
Stroke;
A condition that causes you to have dizzy spells, fainting, or blackouts;
Sleep apnea or narcolepsy;
A history of traumatic brain injury (TBI);
A conditon that causes weakness, shaking or numbness in the arms, hands, legs
or feet that may affect your ability to drive;
A hand, arm, foot or leg that is absent, amputated, or has a loss of function that
may affect your ability to drive;
An eye problem which prevents a corrected minimum visual acuity of 20/70 in at
least one eye or binocular field of vision of at least 110 degrees;
Alcohol use problem;
Drug use problem;
A mental health condition that may affect your ability to drive;
Schizophrenia; or
Dementia.
Comment(s):
-2
Physician/Health Care Provider Report
Page 2
DC-119 2-4 (03/2016)
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