Colorado DR 2401 Form PDF Details

The Colorado DR 2401 form serves as a crucial tool in ensuring road safety, by determining a driver's medical fitness for operating a vehicle. It bridges the gap between public safety and the individual's right to drive, making it a cornerstone document within the Colorado Department of Revenue's Division of Motor Vehicles. The form, which is required to be completed by a certified physician, physician assistant, or nurse practitioner, is a comprehensive medical examination report that covers a wide range of health aspects that could impact driving capabilities. From cardiovascular health to cognitive function, musculoskeletal condition, and even psychiatric or emotional states, the DR 2401 form thoroughly evaluates a driver or patient's fitness for driving, ensuring they can safely control a motor vehicle. It also contains a section for the driver or patient to provide their driving history and habits, which gives a well-rounded view of their driving lifestyle. Significantly, the form allows medical professionals to recommend restrictions to the patient's driving privileges if necessary, such as daylight driving only or no highway driving, ensuring that recommendations are tailored to individual needs and health conditions. By providing a structured framework for evaluating and communicating a person's ability to drive safely, the DR 2401 form represents a critical step in the licensing process, balancing the need for mobility with the paramount importance of road safety.

QuestionAnswer
Form Name Colorado DR 2401 Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names dr2401, colorado dmv eye exam form, colorado 2401, dmv eye exam form

Form Preview Example

DR 2401 (09/14/20)

COLORADO DEPARTMENT OF REVENUE

Division of Motor Vehicles

P.O. Box 173350

Denver CO 80217-3350

FAX: (303) 205-8301

Confidential Medical Examination Report

Driver/Patient Section

Patient Last Name

First Name

 

Middle Initial

 

 

 

 

Street Address

City

State

ZIP

 

 

 

 

Customer Identification Number (CIN)

Date of Birth

 

 

 

 

 

 

Driver Statement of Understanding (Driver signature not required for DMV processing):

My physician will conduct a medical examination to determine my fitness to operate a motor vehicle safely and responsibly.

My physician will respond to any additional questions from the Department of Motor Vehicle (DMV).

I understand that this form will be considered in any decision regarding the issuance of my driver license, pursuant to C.R.S. 42-2-111 & 42-2-112.

Signature of Driver or Patient

Date (MM/DD/YY)

Driver/Patient (respond to all questions below before seeing your physician)

1.How many driving trips do you make in a typical week?

2.Do any of your regular trips involve driving at night?

3.What is the one-way distance of your furthest regular trip

4.Do any of your regular trips involve speeds ≥ 55 MPH?

5.Were you pulled over by a police officer in the past year?

6.Were you involved in a crash as a driver in the past year?

Yes

Yes

Yes

Yes

No Miles

No

No

No

Physician Section

Instructions: use your best clinical judgment as you REVIEW AND COMPLETE ALL SECTIONS. Base severity ratings within each category on your overall assessment of impairment relative to the driving task. Form must be completed by the Physician (MD or DO) or Physician's Assistant (PA). Pursuant to C.R.S. 42-2-112, no civil or criminal action shall be brought against a physician or physician assistant licensed in Colorado for

providing a written medical opinion if the physician or physician assistant acts in good faith and without malice.

Examination Date (MM/DD/YY)

 

 

 

 

 

 

 

Does this patient have:

 

 

 

 

 

 

 

 

 

 

 

(Form is valid for 180 days from date of exam)

 

 

 

 

 

 

Cardiovascular Disease

Yes

No

Are you the primary care provider for this patient

 

Yes

No

 

Cardiac Arrhythmia

 

Yes

No

If yes, how many times have you seen this patient in the past year?

 

 

 

 

 

Heart Failure

 

Yes

No

If no, are you evaluating this patient for the first time today?

 

Yes

No

 

 

 

 

 

 

 

 

If no, have you reviewed the patient's medical records?

 

Yes

No

 

 

 

 

 

To your knowledge, is this patient:

 

 

 

 

 

 

 

 

 

 

 

Aware of his or her medical diagnosis & status?

Yes

Somewhat

No

 

AHA Functional Capacity (circle level if applicable)

Aware of functional impairments that may impact driving?

Yes

Somewhat

No

 

N/A I

II

III IV

 

Compliant with medications & basic requirements of self-care?

Yes

Somewhat

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Need DMV Re-Examination in 1 year?

 

Yes

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Medications

 

 

 

 

 

 

 

 

 

 

 

To your knowledge, is this patient subject to any consistent medicine side effects or interactions that may impair driving ability?

 

 

Yes

Possibly

 

Not Likely

 

 

 

 

No

 

 

 

Page 1 of 2

DR 2401 (09/14/20)

Based on my observations of this patient and information relayed to me by this individual, I, reasonably and in good faith, believe that

_______________________________________________________________________is:

Patient Name

 

 

 

 

Recommended license restriction(s):

Must

 

Fit to operate a motor vehicle safely.

 

 

 

Fit to operate a motor vehicle safely contingent upon passing a DMV Road Test.

Daylight Driving Only

 

Choose

NOT FIT to operate a motor vehicle safely and responsibly due to significant

No Highway/Freeway Driving

One

 

medical-functional compromise or deficit.

 

 

Hand Control

 

 

 

 

{Fitness to drive determination pending; rehab permit required

 

Mile Radius Only ________

 

 

Restricted MPH _________

 

 

Patient also requires an eye exam

 

 

Steering Device

 

 

 

 

Specialty (Required)

License Number (Required)

Phone Number (Required)

Specialty Cushion

 

 

 

 

 

Foot Device

 

 

 

 

 

Automatic Transmission Only

Street Address

City

State

ZIP

 

 

 

 

 

Other_________________________

 

 

 

 

 

Patient Last Name

 

 

First Name

 

Middle Initial

Cognitive, Cerebrovascular or Neurological

Condition is:

Stable

Progressive

N/A

Mental Status__________________________________________________________________________________________ (list test and score)

Confusion or Disorientation

Memory Loss or Forgetfulness

Inattention or Distractibility

Impaired Judgment

Visual-Spatial Deficit

Slowed Processing Speed

Cognitive Impairment

Cerebrovascular Disease

Neurological Condition

 

Alzheimer's Disease

 

 

Cerebral Infarction or Stroke

 

Brain Injury (open or closed)

 

Vascular Dementia

 

 

Hemorrhage or Aneurysm

 

Tumor or Malformation

 

 

Frontotemporal or Pick's

 

Transient Ischemic Attack

 

Parkinson's Disease

 

 

Dementia (other or unknown)

 

Carotid Occlusion or Hypoxia

 

Multiple Sclerosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Combined Impairment for Driving

Unimpaired

 

Very Mild

 

Mild

 

 

Moderate

 

 

Severe

 

 

 

(Likely fit to Drive)

 

(Likely fit to Drive)

(Questionable Fitness)

(Likely Unfit to Drive)

(Unfit to Drive)

Check (X) Highest Level for Section

 

 

Consciousness, Metabolic or Respiratory

 

Condition is:

 

Stable

 

 

Progressive

 

 

N/A

*Date of last event with impaired consciousness (MM/DD/YYYY): _____________________________________________

 

 

 

 

 

 

 

Disorder of Consciousness or Alertness*

 

 

 

 

 

 

 

 

 

 

 

Blackout or Syncope*

 

 

Sleep Apnea or Narcolepsy

 

Medication Effect

 

 

 

 

Chronic Sleep Deprivation

 

Epilepsy or Seizure Disorder

 

Dizziness or Postural Hypotension

 

Metabolic Condition

 

 

 

 

 

 

Respiratory Condition

 

 

 

 

Diabetes (Type 1 or 2)

 

 

 

 

 

 

Asthma or shortness of Breath

 

Thyroid Condition (Hypo or Hyper)

 

 

 

 

 

 

COPD

 

 

 

 

Morbid Obesity or Fluid retention

 

 

 

 

 

 

Oxygen Dependent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Combined Impairment for Driving

Unimpaired

 

Very Mild

 

Mild

 

 

Moderate

 

 

Severe

 

 

 

(Likely fit to Drive)

 

(Likely fit to Drive)

(Questionable Fitness)

(Likely Unfit to Drive)

(Unfit to Drive)

Check (X) Highest Level for Section

 

 

Musculoskeletal, Movement or Neuromuscular

 

Condition is:

 

Stable

 

 

Progressive

 

 

N/A

Check All That Apply:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Arthritis (Osteo or Rheumatoid)

Frailty or General Weakness

Motor Neuron Disease

 

 

Muscular Dystrophy

Uses Cane or Walker

 

 

 

Paralysis - Arm

 

 

Multiple Sclerosis

 

 

Parkinson's Disease

Wheelchair Dependent

 

 

 

Paralysis - Leg

 

 

Restricted or Weakness - Arm

Loss of Limb

 

Difficulty Transferring

 

 

 

Prosthesis or Brace - Arm

Restricted or Weakness - Leg

History of Falls

Problems with Balance

 

 

 

Prosthesis or Brace - Leg

Restricted Neck Range of Motion

Other_____________________

 

 

 

 

 

 

 

 

 

Orthopedic or Movement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Combined Impairment for Driving

Unimpaired

 

Very Mild

 

Mild

 

 

Moderate

 

 

Severe

 

 

 

(Likely fit to Drive)

 

(Likely fit to Drive)

(Questionable Fitness)

(Likely Unfit to Drive)

(Unfit to Drive)

Check (X) Highest Level for Section

 

Psychiatric, Emotional or Addiction

 

 

Condition is:

 

Stable

 

 

Progressive

 

 

N/A

Depression

Bipolar Mood Disorder

Psychosis or Schizophrenia

Alcohol Abuse or Addiction

Drug Abuse or Addition

Suicidal or Homicidal

Anxiety or Post-Traumatic Stress

Chronic Pain (causing distress)

Other ______________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Combined Impairment for Driving

Unimpaired

 

Very Mild

 

Mild

 

 

Moderate

 

 

Severe

Check (X) Highest Level for Section

(Likely fit to Drive)

 

(Likely fit to Drive)

(Questionable Fitness)

(Likely Unfit to Drive)

(Unfit to Drive)

Physician Name (Printed)

 

 

 

 

 

Signature (Required)

 

 

 

 

 

Date (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 2

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2. When the previous array of fields is finished, you're ready include the needed specifics in What is the oneway distance of, Yes, Yes, Instructions use your best, Physician Section, Examination Date MMDDYY Form is, Yes, Aware of functional impairments, Yes, Yes, Does this patient have, Cardiovascular Disease, Cardiac Arrhythmia, Heart Failure, and Yes allowing you to move on to the 3rd stage.

dmv eye exam form conclusion process clarified (portion 2)

3. The following step is considered fairly straightforward, Based on my observations of this, Patient Name, Recommended license restrictions, Daylight Driving Only No, Other, Patient Last Name, Must Choose, One, Fit to operate a motor vehicle, medicalfunctional compromise or, Fitness to drive determination, Specialty Required, Patient also requires an eye exam, License Number Required, and Phone Number Required - all of these empty fields needs to be completed here.

dmv eye exam form conclusion process explained (step 3)

4. The next subsection will require your involvement in the following parts: Impaired Judgment Cognitive, Cerebral Infarction or Stroke, Transient Ischemic Attack, Combined Impairment for Driving, Unimpaired Likely fit to Drive, Carotid Occlusion or Hypoxia, Likely fit to Drive, Questionable Fitness, Condition is, Very Mild, Stable, Mild, Brain Injury open or closed Tumor, Moderate, and Likely Unfit to Drive. Always enter all requested information to go forward.

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