Motor Vehicle Medical Report For Driving Records
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2MOTOR VEHICLE MEDICAL REPORT FOR DRIVING RECORDS
PATIENT’S INFORMATION
LAST NAME
FIRST NAME
MIDDLE INITIAL
DOB
SS NUMBER
DL NUMBER
ADDRESS
CITY
STATE
ZIP CODE
TYPE OF DISEASE OR CONDITION PATIENT IS BEING TREATED FOR:
NEUROLOGICAL
PSYCHOLOGICAL
CARDIOVASCULAR
EPILEPSY
HYPOGLYCEMIA
DIABETES
ORTHOPEDIC
LAPSES OF CONSCIOUSNESS
OTHER
GENERAL QUESTIONS
HOW LONG HAVE YOU BEEN TREATING THE PATIENT?
FREQUENCY OF OFFICE VISITS AND DATE OF LAST EXAMINATION:
DESCRIBE THE NATURE, EXTENT, AND FREQUENCY OF ANY OF THE PATIENT’S SIGNS OR SYMPTONS, ESPECIALLY THOSE THAT MIGHT
AFFECT THE SAFE OPERATION OF A MOTOR VEHICLE:
WHAT IS YOUR DIAGNOSIS AND METHOD OF TREATMENT?
WHAT WAS THE PATIENT’S AGE AT ONSET? GIVEN ANY KNOWN CAUSES.
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