Dmv Form Mv 346 – Fill Out and Use This PDF

STATE OF DELAWARE	DEPARTMENT OF TRANSPORTATION
DIVISION OF MOTOR VEHICLES
DRIVER IMPROVEMENT UNIT ­ MEDICAL RECORDS SECTION
PO BOX 698 ­	DOVER, DE 19903­0698

MEDICAL REPORT OF PHYSICIAN’S FINDINGS

Name: _____________________________________ DOB ___/___/___ License Number: ________________

Address: ___________________________________________________________________________________

I hereby authorize Doctor ___________________________________ to perform any medical examination

necessary for the purpose of determining my fitness to operate a motor vehicle. Also I understand that this authorization includes permission for the Director of Motor Vehicles and/or their designee to have this information reviewed by a Medical Board of unidentified physicians for the purpose of giving him/her a medical opinion on my case for a guidance in determining my medical capabilities to operate a motor vehicle safely. The information contained in this report is confidential and will be used solely for the purpose of drivers license considerations.

_____________________________________	____________________________________________________
Date	Signature of Applicant (Required)
(Legibility is a must)
Mental level for reading (check one) Inadequate	Marginal	Adequate Height: _________ Weight __________

(A)ORTHOPEDIC AND NEUROMUSCULAR: (Please check as appropriate)

(C)DIABETES: (Please check as appropriate)

Is he/she a known diabetic?	YES	NO	Status of Control ______________________________________
Duration: ____________________________			Diabetic Acidosis	YES	NO ________________________

If YES to any of the above, please describe: _______________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

(E)DRUGS AND/OR ALCOHOL: (Please check as appropriate)

Any objective evidence or personal knowledge of addiction, habituation, or alcoholism? YES NO

If YES, please explain: ________________________________________________________________________

___________________________________________________________________________________________

Page (2) Patient Name: __________________________________________________ DOB ___/___/___

(F)PSYCHOLOGICAL ASSESSMENT: (Please check as appropriate)

Is there any evidence of emotional instability?			YES	NO	Is further examination suggested?		YES	NO
Does he/she have or has he/she had any episodes of conditions listed below?
Mental Clouding	YES	NO	Blackouts		YES	NO Dizziness	YES	NO
Unconsciousness	YES	NO	Convulsions		YES	NO

If YES to any of the above, please explain nature and date of last episode:________________________________

___________________________________________________________________________________________

Diagnosis: __________________________________________________________________________________

___________________________________________________________________________________________

(G)Does he/she have any other condition or diseases which would decrease ability to safely operate a motor

vehicle? (Please check as appropriate)

YES

NO

If YES, please explain: ________________________________________________________________________

___________________________________________________________________________________________

(H)What type(s) and quantities of drugs are being prescribed for the patient? _________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

(I)

Do any of the above medications affect driving ability? (Please check as appropriate)

YES

NO

If YES, please explain: ________________________________________________________________________

___________________________________________________________________________________________

(J)

From a medical standpoint, do you feel he/she is capable of operating a vehicle safely?

YES

NO

If NO, please explain: _______________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

If YES, the treating physician must attest to one of the two below listed statements, as may be applicable, for any person who is subject to loss of consciousness due to disease of the central nervous system.

I hereby certify that I am the treating physician duly, licensed to practice medicine and surgery, for the above named individual and that I have been the treating physician for him/her for a period of at least three months, that I am aware of his/her medical history, including his/her history with respect to diseases of the central nervous system, and that such person’s infirmity is under sufficient control to permit him/her to operate a motor vehicle with safety to person and property.

I hereby certify that I am the treating physician, duly licensed to practice medicine and surgery, for the above named individual and that I have been the treating physician for him/her for a period of at least three months, that I am aware of his/her medical history, including his/her history with respect to diseases of the central nervous system, and that such person’s disease no longer requires treatment and that such person can reasonably expect to suffer no further losses of consciousness on account of such disease.

(K)How long have you been treating this patient? ________________ Date of last examination: ___/___/___

(L)Additional comments: ___________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

_____________________________________________________	_______________________________________________________
Physician’s Name (Printed or typed)	Physician’s Signature
_____________________________________________________	_______________________________________________________
Address	Phone Number
_____________________________________________________	Date: __________________________________________________

Please mail form to: MEDICAL RECORDS SECTION ­ DRIVER IMPROVEMENT UNIT ­ PO Box 698 ­ Dover, DE 19903­0698

The form may be transmitted by facsimile to: (302) 739­5667 ATTN.: MEDICAL RECORDS SECTION

FORM: MV­346 – Revised 6/24/2003

Document No. 45­07­93­03­01