Mv3644 - Medical Examination Report
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4MEDICAL EXAMINATION REPORT
Wisconsin Department of Transportation
Clear Form
Medical Review
MV3644
1/2013
Ch. 343 Wis. Stats. & Trans. 112 Admin. Code
PO Box 7918, Madison, WI 53707-7918
Telephone: (608) 266-2327
APPLICANT: After this medical report has been reviewed, you may be required to file medical
FAX: (608) 267-0518
reports on a regular basis. We will send you the forms at the time they are required.
Email: dmvmedical@dot.wi.gov
Applicant Name
Operator License Number
Street Address
Birth Date (m/d/yy)
City, State ZIP Code
(Area Code) Telephone Number
Date Report Issued (m/d/yy)
WisDOT Examiner Badge Number
License Type
CDLI
Passenger Bus
Instruction Permit
Operator
CDL
School Bus
Reason for Referral
HEALTH CARE PROFESSIONAL: Please complete all pertinent sections relative to this person’s health to assist the Department in
making a licensing decision.
Driver Condition or Behavior Report Attached. Driving Incident/Accident Date(s):__________________.
General Medical: complete sections A and G (others if appropriate)
Mental / Emotional: complete sections A, B, and G
Neurological: complete sections A, C, and G
Endocrine (Diabetes): complete sections A, D, and G
Cardiovascular: complete sections A, E, and G
Pulmonary: complete sections A, F, and G
SECTION A
HEALTH CARE PROFESSIONAL - To Complete for ALL Applicants
Provide Diagnoses, Medications Used, and Dosages:
Height
Weight
YES NO
1. Is the person’s condition currently stable? If not, explain below.
2. Is the person reliable in following the treatment program? If not, explain below.
3. Does this person experience side effects of medication which are likely to impair driving ability? If yes, explain below.
4. Has this person experienced an episode of altered consciousness or loss of bodily control during the past 12 months?
If yes, explain below and give date.
5. Does current alcohol/drug abuse/use interfere with medical condition?
If yes, a substance evaluation will be required.
a. Did the person have a seizure(s) related to withdrawal? If yes, explain below and give date.
6 . Does this person experience uncontrolled sleepiness associated with sleep apnea, narcolepsy, or other disorder?
If yes, explain below.
7. Is driving ability likely to be impaired by limitations in any of the following?
a. Judgment and insight
b. Problem-solving and decision-making
c. Emotional or behavioral stability
d. Cognitive function or memory loss
8. Is driving ability likely to be impaired by limitations in any of the following?
a. Reaction time
b. Sensorimotor function
c. Strength and endurance
d. Range of motion
e. Maneuvering skills
f. Use of arm(s) and/or leg(s)
Details and Elaboration
Note: Sections B, C and D are on the next page (over).
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T583 / MV3644
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Parent category: Medical