Motor Vehicle Medical Report For Driving Records Page 2
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2MOTOR VEHICLE MEDICAL REPORT FOR DRIVING RECORDS
IF APPLICABLE GIVE DATES OF LAST RELEVANT TESTS, SPECIFY TESTS, AND PHYSICIAN.
DATE OF LAST BLOOD PRESSURE TEST AND RESULTS.
LIST MEDICATION THE PATIENT IS BEING TREATED WITH.
DOES THE ABOVE MEDICATION IMPAIR THE ABILITY TO SAFELY OPERATE A MOTOR VEHICLE? IF YES, EXPLAIN EFFECT.
IF APPLICABLE, LIST ANY ABNORMAL PERSONALITY TRAITS, ADDICTIONS, ETC.
DO YOU CONSIDER THE PATIENT’S COMPLICATIONS OR CONDITIONS CONTROLLED?
FROM A MEDICAL STANDPOINT ONLY, IS THE PATIENT CAPABLE OF SAFE AND COMPETANT DRIVING?
YES
NO
RECOMMENDED RESTRICTIONS.
INDICATE NEXT RECOMMENDED INTERVAL FOR MEDICAL REPORT REVIEW.
PHYSCIAN’S INFORMATION
NAME
PHONE NUMBER
ADDRESS
CITY
STATE
ZIP CODE
SIGNATURE
DATE
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