Dmv Form Med 2 PDF Details

The Department of Motor Vehicles (DMV) Form Med 2 is a medical form that must be completed by all drivers who have seizures. The form is used to provide information about the driver's condition and medications, in order to help the DMV make decisions about whether or not the driver is safe to operate a motor vehicle. Driver safety is of paramount importance, so it is important for all drivers with seizures to fill out Form Med 2 accurately and completely. The DMV will use the information provided on this form to determine if a driver can continue driving after having a seizure. Any changes in a driver's health or medication should also be reported to the DMV as soon as possible. Filling out Form Med 2 correctly is critical for ensuring that you are able to maintain your driving privileges.

Question	Answer
Form Name	Dmv Form Med 2
Form Length	8 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min
Other names	dmv 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

Describe, in detail, your medical condition.

Do you take prescription/non-prescription medications?

YES

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

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.

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

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

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

Does the patient have a history of seizures?

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

YES

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

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.
	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

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

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

If Yes, explain.

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

YES

If Yes, list dates hospitalized and status upon discharge.

Was the hospitalization voluntary?

YES

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

YES

If Yes, indicate condition.

Do any complications or associated conditions exist?

If Yes, explain.

YES

Does this patient have hypoglycemic reactions?

YES

If Yes, provide dates and reasons.

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

YES

Does this patient demonstrate how to counter a hypoglycemic reaction?

YES

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

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
Hemoglobin A1C Results (30 days)		Attached

Go to Part F

Customer Medical Report

MED 2 (07/01/2011) Page 5

NAME (Last)

(First)

(MI) (Suffix)

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

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 C - CARDIOVASCULAR REPORT (must also complete Part F)

Length of time individual has been your patient.

YEARS MONTHS

Have you examined this individual during the last six months?

YES

NO IF Yes, enter examination date.

EXAMINATION DATE (mm/dd/yyyy)

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

Was the hospitalization voluntary?

YES NO

Does the patient have an implantable cardioverter defibrillator?

YES

If Yes, give implant date.

Has the unit discharged since the implant?

YES

If Yes, describe the patient's condition at the time and date of discharge.

Does the patient have a ventricular assist device system?

YES

If Yes, when was this device implanted?

Has the patient had any of the following:

Cardiovascular surgery and/or other procedures?

YES

If Yes, explain and give dates.

Syncope?

YES

If Yes, explain and give dates.

Attach the following information/documents:

Results of Event Monitor

Results of Holter Monitor

Results of Tilt-table Test

Results of EKG

Fatigue with exertion?

YES

Fatigue at rest?

YES

Dyspnea with exertion?

YES

If Yes, explain and give dates.

Dyspnea at rest?

YES

If Yes, explain and give dates.

Pulmonary symptoms? YES

NO If Yes, explain and give dates.

Go to Part F

Customer Medical Report

MED 2 (07/01/2011) Page 6

NAME (Last)

(First)

(MI) (Suffix)

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

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 D - PULMONARY 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

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

If Yes, explain.

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

YES

If Yes, list dates hospitalized and status upon discharge.

Was the hospitalization voluntary?

YES

Is oxygen use required?

YES

If Yes, describe treatment regimen and provide number of liters.

Fatigue with exertion?

YES

Fatigue at rest?

YES

Dyspnea with exertion?

YES

If Yes, explain and give dates.

Dyspnea at rest?

YES

If Yes, explain and give dates.

Syncope from cough?

YES

NO If Yes, explain cause and resolution.

Does the patient have a diagnosis of sleep apnea, narcolepsy, or other sleep disorder?

YES

Does the pulmonary disease prevent activities of daily living?

YES

If Yes, identify.

Has patient been compliant with treatment to the extent that the symptoms are controlled?

YES

Attach the following information/documents:

Pulse oximetry

room air

oxygen

Results of pulmonary function test

Results of sleep study

Go to Part F

Customer Medical Report

MED 2 (07/01/2011) Page 7

NAME (Last)

(First)

(MI) (Suffix)

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

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 E - PSYCHIATRIC/SUBSTANCE ABUSE REPORT (must also complete Part F)

Length of time individual has been your patient.

YEARS MONTHS

Have you examined this individual during the last six months?

YES

NO IF Yes, enter examination date.

EXAMINATION DATE (mm/dd/yyyy)

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

Was the hospitalization voluntary?

YES NO

Has the patient been hospitalized in the past year for a mental/emotional condition?		YES		NO	If Yes, give admission date(s), reason(s) for admission and date
(s) of discharge.

Does the patient have a condition, which results in one or more of the impairments listed below?

YES

If Yes, check all that apply.

Poor decision-making/problem-solving skills Memory loss, Cognitive

Poor impulse control/extremely impulsive

Hallucinations/delusions

Extremely aggressive/destructive behavior Emotional or behavioral instability

Poor/impaired judgement Dementia/confusion

Identify current treatment program(s), counseling, medications, etc.

Attach the following information/documents, (if available):

MMSE	attached	not available
Neuropsychological Exam		attached
Neuropsychological Exam		attached

not available

Is patient CURRENTLY undergoing OR has patient successfully completed drug/alcohol treatment?

YES

NO If Yes, explain.

Did the patient experience seizure(s) related to withdrawal?

YES

If Yes, give date(s).

Has the patient been compliant with substance abuse treatment?

YES

Attach the following information/documents:

Results of drug/alcohol screening

Report from substance abuse counselor

Recommendations:

Go to Part F

Customer Medical Report

MED 2 (07/01/2011) Page 8

(MUST BE COMPLETED BY PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER)

NAME (Last)

(First)

(MI) (Suffix)

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

PART F - GENERAL RECOMMENDATIONS

FIRST MEDICAL PROVIDER

Is the patient's condition(s) stable?

YES

NO If No, explain.

Is the patient compliant with treatment?

YES

If No, explain:

Does the patient experience side effects of medications, which are likely to impair driving ability?

NO If Yes, explain:

YES

Based on this examination, is the patient medically capable of:

▪ operating a commercial motor vehicle includes tractor trailers, passenger

▪ safely operating a motor vehicle?

YES

and/or

buses, tank vehicles, school buses for 16 or more occupants (including the

driver), or vehicles carrying hazardous materials?

YES

Based on this examination, patient needs the following: (check each appropriate item)

to be retested by DMV on

Knowledge

Road

Both

an adaptive device/equipment required to safely operate a motor vehicle.

a driver evaluation (with a certified independent driver rehabilitation specialist CDRS).

a prosthetic/orthotic device to operate a motor vehicle

For clarification on any of the above, contact Medical Review Services at 804 367-6203.

Based on this examination, the patient's driving ability is likely to be impaired by limitations in the following areas: (check each appropriate item)

Judgment and Insight

Sensorimotor Function

Problem Solving and Decision Making

Cognitive Function

Strength and Endurance

Maneuvering Skills

Emotional or Behavioral Stability

Reaction Time

Range of Motion

Use of Arm(s) and/or Leg(s)

ADDITIONAL RECOMMENDED RESTRICTIONS

MEDICATIONS

PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER NAME (print)

MEDICAL SPECIALTY

MEDICAL LICENSE NUMBER

EXPIRATION DATE (mm/dd/yyyy)ISSUING STATE

TELEPHONE NUMBER

FAX NUMBER

(

)

(

)

PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER SIGNATURE

DATE (mm/dd/yyyy)

If you have questions or need more information to complete this page, call Medical Review Services (804) 367- 6203.

SECOND MEDICAL PROVIDER

Is the patient's condition(s) stable?

YES

NO If No, explain.

Is the patient compliant with treatment?

YES

If No, explain:

Does the patient experience side effects of medications, which are likely to impair driving ability?

NO If Yes, explain:

YES

Based on this examination, is the patient medically capable of:

▪ operating a commercial motor vehicle includes tractor trailers, passenger

▪ safely operating a motor vehicle?

YES

and/or

buses, tank vehicles, school buses for 16 or more occupants (including the

driver), or vehicles carrying hazardous materials?

YES

Based on this examination, patient needs the following: (check each appropriate item)

to be retested by DMV on

Knowledge

Road

Both

an adaptive device/equipment required to safely operate a motor vehicle.

a driver evaluation (with a certified independent driver rehabilitation specialist CDRS).

a prosthetic/orthotic device to operate a motor vehicle

For clarification on any of the above, contact Medical Review Services at 804 367-6203.

Based on this examination, the patient's driving ability is likely to be impaired by limitations in the following areas: (check each appropriate item)

Judgment and Insight

Sensorimotor Function

Problem Solving and Decision Making

Cognitive Function

Strength and Endurance

Maneuvering Skills

Emotional or Behavioral Stability

Reaction Time

Range of Motion

Use of Arm(s) and/or Leg(s)

ADDITIONAL RECOMMENDED RESTRICTIONS

MEDICATIONS

PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER NAME (print)

MEDICAL SPECIALTY

MEDICAL LICENSE NUMBER

EXPIRATION DATE (mm/dd/yyyy)ISSUING STATE

TELEPHONE NUMBER

FAX NUMBER

(

)

(

)

PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER SIGNATURE

DATE (mm/dd/yyyy)

If you have questions or need more information to complete this page, call Medical Review Services (804) 367- 6203.

How to Edit Dmv Form Med 2 Online for Free

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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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