PATIENT’S NAME: ________________________________________________
6. Required:
In the past six months, has the driver’s ability to safely operate a motor vehicle been impaired (due to any reason) or has
driver experienced an attack of unconsciousness? YES
■ NO ■ Date of Attack: ___________________
(
If YES, you must provide details, which may include pertinent clinical information.)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
7. Date of last impaired ability to safely operate a motor vehicle or attack of unconsciousness. Date: ___________________
(
You must provide details, which may include pertinent clinical information.)
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
SECTION III MENTAL HEALTH — To be completed ONLY if driver has a Mental Health Disorder marked “YES” by MD/DO and/or medical
professional (NP/PA).
Mental Health Disorder: YES
■ NO ■
DATE OF COMPLETION OF MENTAL HEALTH SECTION III: _____________________________________
1.
Required: In your professional opinion, is this individual MENTALLY FIT to safely operate a motor vehicle?
YES ■ NO ■
2. Mental Health Disorder Diagnosis/Condition(s): _____________________________________________________________________
3. List all current mental health medications. (If medications are listed, a condition must be disclosed above in Question #2.)_
_______________________________________________________________________________________________________________
_______________________________________________________________________________________________________________
4. ■ No medications prescribed.
5. (A) Controlled
■ (B) Not Controlled: will not affect driving ■ (C) Not Controlled: may affect driving ■
(
If Not Controlled is marked, you must provide details, which may include pertinent clinical information, i.e., test results, lab values.)
_______________________________________________________________________________________________________________
SECTION IV — Additional information, special restrictions, etc.
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
SECTION V — MD/DO and/or medical professional (NP/PA) — Failure to provide license information will result in return of form to
the driver.
(Unacceptable Signatures: Chiropractors, Podiatrists, Residents, Fellows, Interns, RN’s, LPN’s, Co-signatures)
MEDICAL:
______________________________________________________ _______________________________________________________
Provider Name (PRINTED) Medical Provider’s Address (PRINTED/STAMPED)
______________________________________________________ _______________________________________________________
Professional License Number/State License Issued Telephone Number
______________________________________________________ _______________________________________________________
Provider’s SIGNATURE — Date of Completion
■ MD ■ DO ■ NP ■ PA Provider’s Specialty
MENTAL:
______________________________________________________ _______________________________________________________
Provider Name (PRINTED) Medical Provider’s Address (PRINTED/STAMPED)
______________________________________________________ _______________________________________________________
Professional License Number/State License Issued Telephone Number
______________________________________________________ _______________________________________________________
Provider’s SIGNATURE — Date of Completion
■ MD ■ DO ■ NP ■ PA Provider’s Specialty
PLEASE MAINTAIN A COPY FOR YOUR RECORDS.
( )
( )
