Dl 124 Form PDF Details

Navigating the complexities of medical reporting for drivers can be a nuanced process, especially when neurological conditions are involved. The DL-124 form, officially approved by the Medical Advisory Board on November 16, 2012, serves as a critical tool within this framework, designed to assess an individual's neurological fitness for driving. This comprehensive form requires healthcare providers to document detailed patient information, including the presence of any neurological disorders, potential impairments in reaction time, coordination, muscular strength, or any other condition that might affect an individual's ability to drive safely. Furthermore, it delves into cognitive impairments, loss of consciousness episodes, and the impact of any medication on driving capabilities. Submitted to the Bureau of Driver Licensing in Harrisburg, PA, the DL-124 form represents a vital link between medical assessment and the assurance of road safety, underscoring the shared responsibility among healthcare providers, patients, and regulatory bodies to uphold high standards of driving safety. By facilitating a structured evaluation process, the form aims to protect not only the individual driver but also the broader public by addressing risks associated with neurological impairments behind the wheel.

QuestionAnswer
Form NameDl 124 Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesgeneral neurological form, dl 124 form, dot forms for neurological, neurological form template

Form Preview Example

DL-124 (12-12)

GENERAL NEUROLOGICAL FORM

PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION

Bureau of Driver Licensing P.O. Box 68682 Harrisburg, PA 17106-8682 (717) 787-9662

THIS FORM APPROVED BY THE MEDICAL ADVISORY BOARD 11/16/2012

Provider: For more information relating to Medical Reporting, visit http://www.dmv.state.pa.us/centers/medicalReportingCenter.shtml.

PATIENT INFORMATION (Please complete this form in its entirety)

DRIVER’S LICENSE NO.

LAST NAME(S)

JR. ETC FIRST NAME

HEIGHT

SEX

EYE COLOR

 

DATE OF BIRTH

TELEPHONE NUMBER

E-MAIL (if applicable)

FEET

INCHES

 

 

MONTH

DAY

YEAR

 

 

 

 

 

 

 

 

 

 

 

STREET ADDRESS: P.O. Box number may be used in addition to the actual address, but cannot be used as the only address.

CITY

STATE ZIP CODE

1.How long have you been treating the patient?__________________________________________________________________________

2.Has the patient been diagnosed with a neurologic disorder? ______________________________________________________________

3.Has the patient had a loss of consciousness due to cerebral vascular insufficiency? ___________________________________________

If yes, date of last episode:__________________

4.Does the patient have impairment in any of the following areas which would make him/her unsafe to drive?

a.Reaction time? ________________________________________________________________________________________________

b.Coordination of movement of the extremities? _______________________________________________________________________

c.Muscular strength? _____________________________________________________________________________________________

5.Does the patient have any paralysis? __________ If yes, please explain: ___________________________________________________

6.Does the patient have excessive aggressiveness or disregard for the safety of self or others or both that would make him/her

unsafe to drive? _________________________________________________________________________________________________

7.Does the patient have any cognitive impairment(s) which would make him/her unsafe to drive, including but not limited to attentiveness to the task of driving, judgement and problem solving, planning and sequencing, visuospatial perception and or memory? _______________

8.Has the patient had a loss of visual fields?_____________ If yes, please explain: _____________________________________________

9.Is the patient being treated with medicine? __________ If yes, please specify: ______________________________________________

____________________________________________________________________________________________________________

Does the medication(s) make him/her an unsafe driver?

o YES o NO

HEALTH CARE PROVIDER INFORMATION (Please print or type)

HEALTH CARE PROVIDER'S NAME

SPECIALTY

 

HEALTH CARE PROVIDER’S LICENSE NUMBER

 

 

 

 

 

 

 

STREET ADDRESS

CITY

 

STATE

ZIP CODE

 

 

 

 

 

 

 

TELEPHONE NUMBER

 

 

FAX NUMBER

 

 

 

 

 

 

 

 

 

I hereby state that the facts above set forth are true and correct to the best of my knowledge, information and belief. I understand that the statements made herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsiication to authorities) punishable by a ine up to $2,500 and/or

imprisonment up to 1 year.

 

 

 

Health Care Provider's Signature

 

Date

 

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neurological form printable conclusion process clarified (stage 3)

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