Driver Medical Evaluation Form
Evaluator's Name
First Name
Last Name
Evaluation Date
-
Month
-
Day
Year
Date
Patient's Name
First Name
Last Name
Driver License Number
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
List any medication currently prescribed:
Is your patient under a controlled medical program?
Yes
No
Is your patient suffering from any disease or ailment, such as epilepsy, narcolepsy, diabetes, cerebral vascular disease, or any other condition that could result in loss of consciousness or motor function at any time?
Yes
No
Does your patient have any impairments?
Impaired motor function
Reaction, or impairment due to change in medication or dosage
Neurological or neuromuscular disease
Diminished concentration
Diminished judgment
Memory Loss
Alzheimer’s disease
Other
Diagnosis
Can this patient drive in traffic?
Yes
No
Signature
Submit
Should be Empty: