Driver Medical Evaluation Form

Lets a healthcare professional document a driver's physical condition to determine fitness to operate a vehicle.

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Evaluator's Name

Nombre

Apellido

Evaluation Date

Patient's Name

Nombre

Apellido

Driver License Number

Phone Number

List any medication currently prescribed

Is your patient under a controlled medical program?

Yes No

Does your patient suffer from any disease or ailment, such as epilepsy, narcolepsy, diabetes, cerebrovascular disease, or any other condition that could result in a loss of consciousness or motor function at any time?

Yes No

Does your patient have any impairments?

Vision Hearing Mobility Cognitive None

Diagnosis

Can this patient drive in traffic?

Yes No

Signature

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