The URL can be used to link to this page

Home My WebLink About2009-04 Medical Report MEDICAL REPORT DOT-H 2058(4;09) FOR Applicant's Name NOTICE TO APPLICANT: Please take this form to your doctor(licensed M.D.or D.O.).You are responsible for any expense involved. The Medical Advisory Board will review your medical report that will be identified by number only.The board will provide an opinion regarding your fitness to drive safely based on the guidance in the Medical Conditions Affecting Drivers. The County's Examiner of Drivers will review the board's opinion and decide whether you meet the standards required to operate a motor vehicle in the State of Hawaii. NOTICE TO MEDICAL EXAMINER: This applicant is required to undergo a medical examination to provide the driver licensing administrator information to decide whether the physical and mental standards to be licensed in this State are met.Your report will be reviewed by this agency and the Medical Advisory Board before the applicant is licensed.State laws make the licensing administrator responsible for the licensing action and your medical report is strictly advisory.Please be assured that your report will be used to grant driving privileges commensurate with driving ability while considering driving need and public safety. Please complete the form for the medical condition in question so that we may be properly informed about the medical conditions that might impair safe driving ability.If your examination reveals other conditions that in your professional opinion might present a hazard to driving safely,please provide the information.Consult with other medical authorities,if necessary. The applicant is responsible for any professional fee for this examination.The AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION form is for your protection;it should be signed by the applicant and kept in your files. Thank you for your assistance in this program. ......................................................................................................................................................................................... AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION I hereby authorize the release of my medical history to the county examiner of drivers for deciding my eligibility for a driver's license by. Name of M.D.or D.O. Signature of applicant Date DRIVER'S LICENSE NUMBER CASE NUMBER Class Restriction Driver's name Age Tel number Occupation Reason for medical report 1. MEDICAL HISTORY-Complete all items. Yes No ❑ ❑ A. Does your patient have a physical, neurological, or mental impairment that might impair safe driving? B. What is the diagnosis of your patient's illness or injury? C. How long have you treated this patient? When was the most recent visit? D. What medication(s)is the patient taking?Name drugs. How often? DRUG DOSE SCHEDULE 11. MEDICAL CONDITIONS-Complete problem areas only. Yes No ❑ ❑ A. CARDIAC/PULMONARY- Initial if not applicable and skip this section. 1. Vital signs: BP P RR ❑ ❑ Edema? ❑ ❑ Supplemental oxygen needed? ❑ ❑ 2. Does patient have chest pain(angina)or obvious dyspnea? If yes,describe for"at rest", "slight exertion", or"moderate." ❑ ❑ 3. Does patient have any of the following: syncope, vertigo, infarction? If yes, give details. ❑ ❑ 4. Does patient take medication regularly for cardiovascular condition? If yes, explain. 5. Describe any cardiac assistive device, e.g. pacemaker, and give implant date. 6. Describe patient's functional capacity(AMA): Class 1 No limitation physical activity Class 2 Slight limitation physical activity Class 3 Marked limitation physical activity Class 4 Complete limitation physical activity Medical Report-DOT-H 2058(4/09) Page 1 of 4 DRIVER'S LICENSE NUMBER CASE NUMBER Yes No O O B. DiABBES-Initialifmotapplicableandnkip this section. O O 1. Is patient being treated for diabetes? If yes, specify insulin dosage and type or oral medication dosage and type. O O 2. |m there a history of hypoglycemic reactions? O O |f yes, io there any warning ofreactions? O [] If no, does the patient check his/her own blood sugar, using a glucose meter, before driving? O O 3. If taking insulin, or oral medication, does the patient carry glucose tablets or candy at all times? O O 4. |e diabetes under control? O O C NEUROLOGICAL Initial if not applicable and skip this section. O O 1. Does your patient have a history of seizures, syncopal attacks, or disabling dizziness? 2. What in the frequency of these episodes? When was the last episode? O O 3, Does your patient presently have any neurological impairment? |f so, please detail. O O 4. Do you expect the patient will bu free of seizures in the future? • O D ORTHOPEDIC'Initial___if not applicable and skip this section. • O 1. Does the patient have an amputation or skeletal defect that can interfere with driving ability? If yes, give details. O O 2. Does the patient use an artificial limb? |f yes, explain. O O 3. Has the patient any paralysis,joint stiffness, reduced physical dexterity, or limitation of motion sufficient ho interfere with driving safely? If yes, give details. O O 4. |n condition stable? xn&uomort DOT-nz05e(4x09) Page zof4 DRIVER'S LICENSE NUMBER CASE NUMBER Yes No C. ❑ E. MENTAL HEALTH-Initial if not applicable and skip this section. ❑ ❑ 1. In the past three years, has the patient demonstrated hallucinations,delusions, drinking, drug abuse, impulsive, assaultive, homicidal, or suicidal behavior or other symptoms or signs indicating treatment was needed?Please list. ❑ ❑ 2. In the past three years, have treatment recommendations been followed?Describe hospitalizations, residential, OPD, psychotherapy, medication,AA, NA, anger management. 3. Current diagnosis. 4. Current treatment. ❑ ❑ F. ALCOHOL/SUBSTANCE ABUSE- Initial if not applicable and skip this section. ❑ ❑ 1. Does your patient have a history of: ❑ ❑ Alcohol abuse? ❑ ❑ Stimulants(cocaine, methamphetamine)abuse? ❑ ❑ Others? If yes, specify. ❑ ❑ 2. Is your patient being treated for alcohol/substance abuse? Date(s)of last use of alcohol. Date(s)of last use of other substances(marijuana, cocaine, methamphetamine). ❑ ❑ 3. Is your patient currently clean and sober?If yes,for how long? ❑ ❑ 4. Does your patient go to AA/NA meetings three times per week? ❑ ❑ 5. If you are not treating this patient for alcohol/substance abuse, is the patient seeing: ❑ ❑ A certified substance abuse counselor? ❑ ❑ A psychologist? ❑ ❑ A psychiatrist(physician)? ❑ ❑ G. VISION- Initial if not applicable and skip this section. 1. Visual Acuities: ❑ ❑ a. Are there medical conditions or medications that could affect patient's visual acuities? If yes, list conditions: b. Distance Visual Acuities: Uncorrected Corrected with present lenses Right eye 201 201 Left eye 20! 201 Yes No Medical Report-DOT-H2058(4109) Page.3 of 4 omvsnS LICENSE NUMBER CASE NUMBER 2. Visual I5elds: O B a. Are there medical conditions that could affect patient's visual fields? b. If yes, list condition(s)and either attach a copy of visual fields testing, or fill in the amount of visual fields in each eye. Condition(s): Right eye Leftmyo:______degne*s O O H. HEARING'Initial if not applicable and skip this section. O O 1. Does patient have u hearing problem? |f yes, describe. UL CONCLUSION—Complete all items. *ox No o o A. *AT PATIENT'S LAST VISIT,WAS PATIENT'S CONDITION QR MEDICATIONS LIKELY TO INTERFERE WITH SAFE DRIVING? o o B. *IN YOUR OPINION, |8 THIS PERSON CAPABLE OF SAFE DRIVING? El o C. *DO YOU RECOMMEND A ROAD TEST? D. *IN YOUR OP|N|ON, HOW OFTEN SHOULD THIS PERSON'S DRIVING ABILITY BE REEVALUATED 8YTHE DK8V? Every_____year(o) E. *WHAT RENEWAL PERIOD DO YOU RECOMMEND FOR THIS DRIVER?(License terms: Age 1040=0-month provisional license until 19; 17-24=4 years;25-71 =8 years; 72+=2 years.) _______ymar(e) *These items must bncompleted, |oanify that| have examined this applicant. Print name of reporting physician Check one: 0 MID Date of examination Office telephone number 11 DO Signature of reporting physician Medical license number Specialty - '