Laserfiche WebLink
DRIVER'S LICENSE NUMBER CASE NUMBER <br /> Yes No <br /> C. ❑ E. MENTAL HEALTH-Initial if not applicable and skip this section. <br /> ❑ ❑ 1. In the past three years, has the patient demonstrated hallucinations,delusions, drinking, <br /> drug abuse, impulsive, assaultive, homicidal, or suicidal behavior or other symptoms or <br /> signs indicating treatment was needed?Please list. <br /> ❑ ❑ 2. In the past three years, have treatment recommendations been followed?Describe <br /> hospitalizations, residential, OPD, psychotherapy, medication,AA, NA, anger <br /> management. <br /> 3. Current diagnosis. <br /> 4. Current treatment. <br /> ❑ ❑ F. ALCOHOL/SUBSTANCE ABUSE- Initial if not applicable and skip this section. <br /> ❑ ❑ 1. Does your patient have a history of: <br /> ❑ ❑ Alcohol abuse? <br /> ❑ ❑ Stimulants(cocaine, methamphetamine)abuse? <br /> ❑ ❑ Others? If yes, specify. <br /> ❑ ❑ 2. Is your patient being treated for alcohol/substance abuse? <br /> Date(s)of last use of alcohol. <br /> Date(s)of last use of other substances(marijuana, cocaine, methamphetamine). <br /> ❑ ❑ 3. Is your patient currently clean and sober?If yes,for how long? <br /> ❑ ❑ 4. Does your patient go to AA/NA meetings three times per week? <br /> ❑ ❑ 5. If you are not treating this patient for alcohol/substance abuse, is the patient seeing: <br /> ❑ ❑ A certified substance abuse counselor? <br /> ❑ ❑ A psychologist? <br /> ❑ ❑ A psychiatrist(physician)? <br /> ❑ ❑ G. VISION- Initial if not applicable and skip this section. <br /> 1. Visual Acuities: <br /> ❑ ❑ a. Are there medical conditions or medications that could affect patient's visual acuities? <br /> If yes, list conditions: <br /> b. Distance Visual Acuities: <br /> Uncorrected Corrected with present lenses <br /> Right eye 201 201 <br /> Left eye 20! 201 <br /> Yes No <br /> Medical Report-DOT-H2058(4109) Page.3 of 4 <br />