Form Cdph 110c - Confidential Morbidity Report
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1
2State of California—Health and Human Services Agency
California Department of Public Health
CONFIDENTIAL MORBIDITY REPORT
PLEASE NOTE: Use this form for reporting lapses of consciousness, Alzheimer's disease or other conditions which may impair the
ability to operate a motor vehicle safely (pursuant to H&S 103900).
CONDITION BEING REPORTED
Patient Name - Last Name
First Name
MI
Ethnicity (check one)
Hispanic/Latino
Non-Hispanic/Non-Latino
Unknown
Race (check all that apply)
Home Address: Number, Street
Apt./Unit No.
African-American/Black
American Indian/Alaska Native
City
State
ZIP Code
Asian (check all that apply)
Asian Indian
Hmong
Thai
Home Telephone Number
Cell Telephone Number
Work Telephone Number
Cambodian
Japanese
Vietnamese
Chinese
Korean
Other (specify):
Email Address
Primary
English
Spanish
Filipino
Laotian
Language
Other: ______________
Pacific Islander (check all that apply)
Birth Date (mm/dd/yyyy)
Age
Gender
Native Hawaiian
Samoan
Years
M to F Transgender
Male
Guamanian
Other (specify): ________
Months
F to M Transgender
Female
White
Days
Other: ____________
Pregnant?
Est. Delivery Date (mm/dd/yyyy)
Country of Birth
Other (specify): _______________
Unknown
Yes
No
Unknown
Occupation or Job Title
Occupational or Exposure Setting (check all that apply):
Food Service
Day Care
Health Care
Correctional Facility
School
Other (specify): _______________________________________
Date of Onset (mm/dd/yyyy)
Date of First Specimen Collection (mm/dd/yyyy)
Date of Diagnosis (mm/dd/yyyy)
Reporting Health Care Provider
Reporting Health Care Facility
REPORT TO:
Address: Number, Street
Suite/Unit No.
EPIDEMIOLOGY
City
State
ZIP Code
Fax (858) 715-6458
Phone (619) 692-8499
Telephone Number
Fax Number
Submitted by
Date Submitted (mm/dd/yyyy)
(Obtain additional forms from your local health department.)
DEPARTMENT OF MOTOR VEHICLES (DMV)
California Driver License or Identification Card Number (eight characters):
1. If this report is based upon episodic lapses of consciousness, when was the most recent episode?: _______________
(mm/dd/yyyy)
2. If there have been multiple episodes of loss of consciousness or control within the past three years, please indicate the dates if they are known to you.
(a):
(b):
(c):
(d):
(e):
(f):
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
3. Within the past 12 months, has there been an episode of loss of consciousness or control while driving?
Yes
No
Uncertain
4. Are additional lapses of consciousness likely to occur?
Yes
No
Uncertain
5. If the patient has had episodes of nocturnal seizures, is there likelihood of lapses of consciousness
Yes
No
Uncertain
occurring while he/she is awake?
6. Has this patient been diagnosed with dementia or Alzheimer's disease?
Yes
No
Uncertain
7. Would you currently advise this patient not to drive because of his/her medical condition?
Yes
No
Uncertain
8. Does this patient's condition represent a permanent driving disability?
Yes
No
Uncertain
9. Would you recommend a driving evaluation by DMV?
Yes
No
Uncertain
Remarks:
CDPH 110c (07/16)
(for reporting conditions reportable to DMV)
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