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Driver Medical Examination Records

Use these forms to request information from a doctor about an employees medical conditions related to driving a commercial motor vehicle.







Medical Report For Driving Records

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Blank report for a driver's doctor to complete providing their medical records related to driving a commercial motor vehicle.

PATIENTíS 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 PATIENTíS 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 PATIENTíS AGE AT ONSET? GIVEN ANY KNOWN CAUSES.


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.


DOES THE ABOVE MEDICATION IMPAIR THE ABILITY TO SAFELY OPERATE A MOTOR VEHICLE? IF YES, EXPLAIN EFFECT.


DO YOU CONSIDER THE PATIENTíS 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.


PHYSCIANíS INFORMATION
NAME PHONE NUMBER
ADDRESS
CITY STATE ZIP CODE
SIGNATURE DATE






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