Confidential Morbidity Report Form – Fill Out and Use This PDF

State of California—Health and Human Services Agency

California Department of Public Health

Patient Name - Last Name

First Name

MI

Ethnicity (check one)

Hispanic/Latino

Non-Hispanic/Non-Latino

Unknown

Race (check all that apply)

Home Address: Number, Street

Apt./Unit No.

African-American/Black

American Indian/Alaska Native

City

State

ZIP Code

Asian (check all that apply)

Asian Indian

Hmong

Thai

Home Telephone Number

Cell Telephone Number

Work Telephone Number

Cambodian

Japanese

Vietnamese

Chinese

Korean

Other (specify):

Email Address

Primary

English

Spanish

Filipino

Laotian

Language

Other: ______________

Pacific Islander

(check all that apply)

Birth Date (mm/dd/yyyy)

Age

Years

Gender

M to F Transgender

Native Hawaiian

Samoan

Months

Male

F to M Transgender

Guamanian

Other (specify): ________

Female

Days

Other: ____________

White

Pregnant?

Est. Delivery Date (mm/dd/yyyy)

Country of Birth

Other (specify): _______________

Yes

No

Unknown

Unknown

Occupation or Job Title

Occupational or Exposure Setting (check all that apply):

Food Service

Day Care

Health Care

Correctional Facility

School

Other (specify): _______________________________________

Date of Onset (mm/dd/yyyy)

Date of First Specimen Collection (mm/dd/yyyy)

Date of Diagnosis (mm/dd/yyyy)

Reporting Health Care Provider

Reporting Health Care Facility

REPORT TO:

Address: Number, Street

Suite/Unit No.

City

State

ZIP Code

Telephone Number

Fax Number

Submitted by

Date Submitted (mm/dd/yyyy)

(Obtain additional forms from your local health department.)

DEPARTMENT OF MOTOR VEHICLES (DMV)

California Driver License or Identification Card Number (eight characters):

1.

If this report is based upon episodic lapses of consciousness, when was the most recent episode?: _______________

(mm/dd/yyyy)

2.

If there have been multiple episodes of loss of consciousness or control within the past three years, please indicate the dates if they are known to you.

(a):

(b):

(c):

(d):

(e):

(f):

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

(mm/dd/yyyy)

3.

Within the past 12 months, has there been an episode of loss of consciousness or control while driving?

Yes

No

Uncertain

4.

Are additional lapses of consciousness likely to occur?

Yes

No

Uncertain

5.

If the patient has had episodes of nocturnal seizures, is there likelihood of lapses of consciousness

Yes

No

Uncertain

occurring while he/she is awake?

6.

Has this patient been diagnosed with dementia or Alzheimer's disease?

Yes

No

Uncertain

7.

Would you currently advise this patient not to drive because of his/her medical condition?

Yes

No

Uncertain

8.

Does this patient's condition represent a permanent driving disability?

Yes

No

Uncertain

9.

Would you recommend a driving evaluation by DMV?

Yes

No

Uncertain

CDPH 110c (10/11) (for reporting conditions reportable to DMV)

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State of California—Health and Human Services Agency

California Department of Public Health

CDPH 110c (10/11)

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