Medical Examination Form - Louisiana Department Of Public Safety & Corrections
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2LOUISIANA DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF MOTOR VEHICLES
MEDICAL EXAMINATION FORM
P. O. BOX 64886 • BATON ROUGE, LA 70896-4886
The bearer of this medical examination form is being required to undergo an examination by a physician. Authority for the requirement is based on laws of
the State of Louisiana relating to the issuance of drivers’ licenses. The completed report of examination will be used by the Department of Public Safety and
Corrections as a guide in making a final determination on the bearer’s application, which is now pending.
NOTE TO APPLICANT: This medical examination form must be completed by your physician and returned to this office within 30
days from the “DATE ISSUED” indicated below. Failure to comply will result in the suspension of your driving privileges.
1.
TO BE COMPLETED BY THE OFFICE OF MOTOR VEHICLES
APPLICANT’S NAME _______________________________________ DOB _______________ R/S_______ D/L#_______________
ADDRESS _____________________________________________ CITY _______________________________________________
DATE ISSUED ______________________ MVCA’S INITIALS _________________ BADGE# ______________ OFFICE# ________
REMARKS: ________________________________________________________________________________________________
__________________________________________________________________________________________________________
APPLICANT FAILED TO COMPLY WITHIN 30 DAYS.
NOTE TO PHYSICIAN: In accordance with the provisions of R. S. 40:1356, a health care provider is exempt from any liability as a result of
reporting to the Department of Public Safety and Corrections any visual ability, physical condition, impairment or disability which may impair
a person’s ability to exercise ordinary and reasonable control in the operation of a motor vehicle. This form must be completed in its entirety
by the physician. Incomplete forms may be rejected and could result in the denial of this applicant’s driving privileges.
2.
TO BE COMPLETED BY THE PHYSICIAN
1.
Patient’s Name: ____________________________________________________ Date of Birth: _____________________
2.
Does patient have any medical or physical disorders? _________ If yes, list the medical or physical disorders __________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3.
Is patient taking any medication? _________ If yes, list current medication and dosage __________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
4.
Has patient had any past surgical procedures? _________ If yes, list the past surgical procedures ___________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
5.
Has patient had any illness that could affect the ability to operate a motor vehicle safely? __________ If yes, describe the
illness __________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
6.
Has patient’s driving privileges ever been withdrawn for a medical or physical disorder? ____________________________
1.
What is patient’s visual acuity without corrective lens? Right eye 20/________ Left eye 20/_______ Both eyes 20/_______
2.
Are corrective lens worn? ______ If yes, with corrective lens: Right eye 20/ _____ Left eye 20/ _____ Both eyes 20/ _____
3.
What are patient’s peripheral vision fields? ________________ Right eye ________________ Left eye _______________
Applicant can recognize and distinguish among traffic control signals and devices showing standard red, green and amber?
□
□
Yes
No
1.
Does the patient have any hearing impairment? _______ If yes, describe the hearing impairment ____________________
__________________________________________________________________________________________________
2.
Is a hearing aid worn? _________ If yes, does it give sufficient correction? ______________________________________
1.
Does patient have any amputation or skeletal deficits that could interfere with the ability to operate a motor vehicle safely?
_____ If yes, describe the deficits in detail ________________________________________________________________
_________________________________________________________________________________________________
2.
Does patient have stiff or frail joints? _______ If yes, describe ________________________________________________
_________________________________________________________________________________________________
3.
Does patient have spastic or paralyzed muscles? _______ If yes, describe ______________________________________
_________________________________________________________________________________________________
4.
Does patient have any orthopedic appliances or supports? _______ If yes, list any device or support and how long used __
__________________________________________________________________________________________________
5.
Does this device provide adequate compensation for operating a motor vehicle safely? ____________________________
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