Dmv Form Med 2 PDF Details

Gathering medical information for driving purposes requires a detailed and structured process, embodied in the DMV Med 2 form. Designed to facilitate a comprehensive review of a driver's medical fitness, this form involves participation from both the individual concerned and their healthcare provider. Individuals are responsible for completing sections related to their personal information and providing consent for the release of medical data to the Department of Motor Vehicles (DMV). The healthcare provider's role is crucial, as they complete parts of the form that relate specifically to the patient's medical conditions, ensuring that all necessary details regarding impairment, medication, and any events like seizures or blackouts that could affect driving abilities are thoroughly documented. The form also addresses specific needs, such as requirements for commercial driver license disability waivers or hazardous materials variances, emphasizing the importance of accurate, up-to-date medical information in the assessment of one's ability to drive safely. It's clear that the DMV Med 2 form serves as an essential tool in the collaborative effort between drivers, healthcare providers, and the DMV to maintain road safety through rigorous medical scrutiny.

QuestionAnswer
Form NameDmv Form Med 2
Form Length8 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min
Other namesdmv customer medical report, Sensorimotor, A1C, Virginia

Form Preview Example

MED 2 (07/01/2011)

CUSTOMER MEDICAL REPORT

Purpose: Use this form to request medical information from your physician, physician assistant or nurse practitioner.

Instructions: Follow the detailed INSTRUCTIONS printed on page 2. Complete the Customer Information and Information Release Approval sections on this page. Take the entire MED 2 and DMV letter to your physician, physician assistant or nurse practitioner to complete the sections that pertain to your medical condition. Part F must be completed by your physician, physician assistant or nurse practitioner. Note: Any charges related to or incurred as part of the completion of this form are the customer's responsibility.

CUSTOMER INFORMATION

NAME (Last)

 

 

 

(First)

 

 

 

 

 

(MI)

(Suffix)

 

CUSTOMER NUMBER (from your driver's license) or SSN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RESIDENCE/HOME ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Check if this is a new address, your address will be changed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

on DMV's system.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

STATE

ZIP CODE

 

CITY OR COUNTY OF RESIDENCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MAILING ADDRESS (if different from above)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITY

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STATE

ZIP CODE

 

DAYTIME TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTH DATE (mm/dd/yyyy)

GENDER

 

 

 

WEIGHT

 

 

 

 

 

HEIGHT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MALE

 

FEMALE

 

 

 

 

 

 

lbs

 

FT

 

 

IN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Describe, in detail, your medical condition.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you take prescription/non-prescription medications?

 

YES

 

NO

 

If Yes, list below. (attach a separate sheet if more space is required)

NON-PRESCRIPTION MEDICATION

 

DOSAGE

 

TIME(S) TAKEN

 

 

PRESCRIPTION MEDICATION

DOSAGE

 

 

TIME(S) TAKEN

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Have you ever experienced a blackout, seizure, loss of consciousness, or syncope?

 

DATE (mm/dd/yyyy)

 

 

Did the episode result in a motor vehicle crash?

 

 

YES

 

NO If Yes, enter date of last episode.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Explain what happened during the episode.

COMMERCIAL DRIVER LICENSE DISABILITY WAIVER OR HAZARDOUS MATERIALS VARIANCE

Are you applying for a commercial driver license disability waiver or a hazardous materials variance? YES If YES, a CDL Disability Waiver or Hazardous Materials Variance Application (MED 30) must also be submitted.

NO

INFORMATION RELEASE APPROVAL

I authorize ________________________________________________ and/or_______________________________________________________,

a licensed medical provider to complete this Customer Medical Report, submit it to DMV and, if necessary to provide further clarification or information to DMV about my physical and/or mental condition. I consent to DMV using this information to arrive at a decision concerning my ability to safely operate a motor vehicle. I also authorize DMV to use the above customer information to correctly identify my records on file in accordance with the Virginia Privacy Protection Act of 1976. I understand that Virginia Code § 46.2-208(b)(1) prohibits DMV from releasing medical data to anyone other than a physician, physician assistant or nurse practitioner

CUSTOMER SIGNATURE AND AUTHORIZATION (parent must sign for a minor)

DATE (mm/dd/yyyy)

MED 2 (07/01/2011)

Page 2

CUSTOMER MEDICAL REPORT

INSTRUCTIONS

Purpose: Use these instructions to complete the Customer Medical Report (MED 2).

CUSTOMER INSTRUCTIONS

1.Review all correspondence received from the Department of Motor Vehicles (DMV) regarding concerns about your ability to safely operate a motor vehicle.

n If you received an Official Notice/Order of Suspension, you must provide DMV with the required Customer Medical Report, (MED 2) prior to the effective date noted in the Notice/Order to avoid having your driving privilege suspended.

n If your driving privilege is suspended, you will be required to provide proof of legal presence in order to reinstate your driver's license, if you have not already provided proof.

2.Complete the sections of the MED 2 titled “Customer Information” and “Information Release Approval”. Be sure to provide your signature at the end of the “Information Release Approval” section.

3.Take the entire MED 2 and your DMV letter to your medical provider at the time of your medical examination.

4.Request your medical provider to complete the parts of the MED 2 that pertain to your medical condition(s) and Part F and return the report to DMV (following medical provider instructions below).

n The medical examination must be conducted after the issue date of your Official Notice/Order of Suspension.

n If you were involved in a recent motor vehicle crash or have experienced a recent blackout, seizure or loss of consciousness, the MED 2 report must reference these incidents and/or events.

Note: you will be notified of any decisions regarding your driving privilege based on:

mMedical and other related information received from your medical provider,

mDMV driver license test results and/or a certified independent driver rehabilitation evaluation (if required),

mDMV medical review policies and guidelines as established in collaboration with the DMV Medical Advisory Board.

5.If you have questions related to DMV's requirement for you to submit a MED 2, you may contact DMV Medical Review Services: n Mail - send your request in writing to Medical Review Services at the address listed at the top of this form

n Telephone - (Voice) 1-804-367-6203 or (Deaf/Hearing Impaired only) 1-800-272-9268

MEDICAL PROVIDER INSTRUCTIONS

1.The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of

medication(s) which may result in impaired:

m level of consciousness/alertness m vision/perception m motor skills/range of motion

m judgment/cognitive function m reaction time

2.Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s).

n If your patient was involved in a recent motor vehicle crash or has experienced a recent blackout, seizure or loss of consciousness, the MED 2 report must reference these incidents and/or events.

n For medical conditions, complete one or more of the following specific report sections: m Neurological/Musculoskeletal - Part A & F

m Metabolic - Part B & F

m Cardiovascular - Part C & F m Pulmonary - Part D & F

m Psychiatric/Substance Abuse - Part E & F

NOTE: Only one Part F is required if the same medical provider completes multiple report sections.

3.In lieu of completing the MED 2, you may submit a letter, note or copies of records as long as the information you submit addresses all of the information requested on the MED 2.

4.Return the completed MED 2 to DMV by mailing it to DMV Medical Review Services at the address on the top of this form.

5.For additional information on DMV's medical review process, you may refer to www.dmvnow.com under "Citizen Services", then "Medical Information", or contact Medical Review Services at 804-367-6203.

Customer Medical Report

MED 2 (07/01/2011) Page 3

NAME (Last)

(First)

(MI) (Suffix)

BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER or SSN

The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired: m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time

Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.

PART A - NEUROLOGICAL/ MUSCULOSKELETAL REPORT (must also complete Part F)

Length of time individual has been your patient.

 

 

 

 

Have you examined this individual during the last six months?

EXAMINATION DATE (mm/dd/yyyy)

YEARS

 

MONTHS

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

NO

IF Yes, enter examination date.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIAGNOSIS(ES) (In order of severity or by current treatment)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are there any complications related to this/these condition(s)?

 

 

YES

 

 

 

NO

 

If Yes, explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has the patient been hospitalized for the above condition(s) within the past year?

 

YES

 

NO If Yes, list dates hospitalized and status upon discharge.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was the hospitalization voluntary?

 

YES

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the patient have a history of seizures?

 

 

 

 

 

If Yes, provide date of each episode and reason(s).

 

 

 

YES

 

 

NO

 

Indicate the risk for further episodes.

Did any seizure result in a motor vehicle crash?

 

YES

 

NO If Yes, enter date of crash.

DATE OF CRASH (mm/dd/yyyy)

Was the last medication blood serum level within acceptable range?

 

YES

 

NO

If No, provide results of blood test.

BLOOD TEST RESULTS

Does the patient have any motor deficits/nerve problems that would impair his/her ability to drive?

 

 

YES

 

NO

 

 

 

 

 

 

 

Does the patient have any other neurological condition(s) that might affect his/her driving?

 

YES

 

 

NO

If Yes, describe the condition(s) and its effect on the

patient's driving.

 

 

 

 

 

 

 

 

Does the patient have any chronic conditions, chronic pain syndromes, fibromyalgia or any movement disorders? YES

NO If Yes, specify.

Is the patient prescribed medication for chronic pain or long-acting narcotics? YES NO If Yes, list the medication(s).

Does the patient have the use of all extremities?

 

 

YES

 

 

NO If No, which extremities are impaired?

 

 

 

 

 

 

 

Does the patient suffer from peripheral neuropathy?

 

YES

 

 

NO

If Yes, which extremities are impaired?

Current blood levels of anticonvulsant medication

TEST DATE (mm/dd/yyyy)

Results of most recent EEG

 

 

Does the neuropathy affect the patient's ability to safely operate a motor vehicle? YES NO

Does the patient suffer from muscle spasms?

 

YES

 

NO

 

 

 

 

 

 

 

 

 

Does the patient have full range of motion of the head and neck?

 

YES

 

NO If No, describe range of motion.

Is adaptive equipment recommended? YES NO If Yes, what type of adaptive equipment does the patient require?

Does the patient require a driver evaluation?

 

YES

 

NO If Yes, examination should be with:

 

an independent certified driver rehabilitation specialist (CDRS)

 

 

a DMV Examiner

 

or both.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Go to Part F

Customer Medical Report

MED 2 (07/01/2011) Page 4

NAME (Last)

(First)

(MI) (Suffix)

BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER or SSN

The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired: m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time

Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.

PART B - METABOLIC REPORT (must also complete Part F)

Length of time individual has been your patient.

 

 

 

 

 

Have you examined this individual during the last six months?

 

EXAMINATION DATE (mm/dd/yyyy)

YEARS

 

MONTHS

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

 

 

 

 

 

 

 

NO

 

 

IF Yes, enter examination date.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIAGNOSIS(ES) (In order of severity or by current treatment)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are there any complications related to this/these condition(s)?

 

 

 

YES

 

 

 

 

NO

 

 

 

If Yes, explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has the patient been hospitalized for the above condition(s) within the past year?

 

 

 

 

YES

 

 

NO

If Yes, list dates hospitalized and status upon discharge.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Was the hospitalization voluntary?

 

YES

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the patient have diabetes or any other metabolic condition(s) that might affect vehicle operation?

 

YES

 

 

NO

If Yes, indicate condition.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do any complications or associated conditions exist?

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, explain.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this patient have hypoglycemic reactions?

 

 

YES

 

 

 

 

NO

 

 

If Yes, provide dates and reasons.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did the hypoglycemic reaction(s) result in a motor vehicle crash(es)?

 

 

 

 

YES

 

 

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does this patient demonstrate how to counter a hypoglycemic reaction?

 

 

 

 

 

YES

 

 

 

 

NO

If Yes, explain how.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has this patient been hospitalized for treatment of diabetes/hypoglycemia or complications in the past year?

 

 

YES

 

NO If Yes, explain

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Does the patient monitor his/her blood sugar?

 

 

YES

 

 

 

 

NO

 

 

If Yes, how often?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Attach the following information/documents, If you suffered a hypoglycemic event, please ensure that your blood sugar logs reflect the last 15 days and your A1C results are drawn after the incident occurred and within the last 30 days.

Blood Sugar Logs (15 days)

 

Attached

Hemoglobin A1C Results (30 days)

 

Attached

 

Go to Part F

How to Edit Dmv Form Med 2 Online for Free

2011 can be completed online without difficulty. Just use FormsPal PDF editor to get it done in a timely fashion. The editor is consistently improved by our staff, acquiring handy functions and becoming better. Should you be seeking to start, here is what it requires:

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This document requires particular data to be entered, hence you need to take whatever time to fill in what's expected:

1. When submitting the 2011, be certain to include all of the important blank fields within its corresponding section. It will help speed up the process, allowing your information to be handled fast and properly.

customer medical report writing process explained (part 1)

2. Once this array of fields is done, you need to include the needed details in Have you ever experienced a, YES, DATE mmddyyyy, Did the episode result in a motor, YES, Explain what happened during the, COMMERCIAL DRIVER LICENSE, YES, INFORMATION RELEASE APPROVAL, I authorize andor a licensed, CUSTOMER SIGNATURE AND, and DATE mmddyyyy in order to move on further.

The best ways to fill out customer medical report step 2

3. This next segment is focused on NAME Last, First, Suffix, BIRTH DATE mmddyyyy, CUSTOMER NUMBER or SSN, Customer Medical Report, MED Page, The Department of Motor Vehicles, Based on the examination that you, PART A NEUROLOGICAL, Length of time individual has been, Have you examined this individual, EXAMINATION DATE mmddyyyy, YEARS, and MONTHS - type in all of these blank fields.

Writing section 3 in customer medical report

4. Filling in Was the last medication blood, YES, BLOOD TEST RESULTS, Does the patient have any motor, Does the patient have any other, YES, Does the patient have any chronic, YES, Is the patient prescribed, YES, Does the patient have the use of, YES, Does the patient suffer from, YES, and Current blood levels of is key in this next part - be certain to don't hurry and take a close look at every blank!

Filling in part 4 in customer medical report

As to YES and YES, make sure that you review things in this section. Both of these are the key ones in the page.

5. And finally, the following final section is precisely what you'll have to finish prior to finalizing the PDF. The blank fields at issue are the following: Does the patient have full range, YES, Is adaptive equipment recommended, YES, Does the patient require a driver, YES, an independent certified driver, a DMV Examiner, or both, and Go to Part F.

The right way to prepare customer medical report part 5

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