Form Dl 121 PDF Details

Understanding the DL-121 form requires delving into the intersection of health, safety, and legality within the sphere of driving licensure in Pennsylvania. Approved by the Medical Advisory Board on November 16, 2012, this particular document, officially titled the Seizure Reporting Form, serves a critical role in safeguarding public roads by regulating the driving privileges of individuals experiencing seizures. Healthcare providers are tasked with completing this form in meticulous detail, encompassing patient information that includes the history and specifics of seizure events, alongside any treatments—such as medication—that might influence a patient's ability to safely operate a vehicle. The DL-121 form not only gathers data regarding the occurrence of seizures but also delves into related elements like the presence of electrically diagnosed seizure disorders, episodes of loss of consciousness, and the potential impacts of medication changes on seizure activity. Furthermore, it differentiates between seizures linked to enduring conditions and those resulting from transient causes like illness or metabolic imbalances. With the submission of this form, healthcare providers affirm under penalty for falsification that the information provided is accurate, embedding a legal obligation into the monitoring process of drivers with seizure disorders. This system illustrates a nuanced approach to driver licensing, where the aim is to balance the rights of individuals against the imperative of road safety.

QuestionAnswer
Form NameForm Dl 121
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespenndot seizure reporting, penndot medical reporting form, dmv seizure form, penndot seizure reporting form

Form Preview Example

DL-121 (12-12)

SEIZURE REPORTING 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.Did the patient have a seizure?____________________________________________________________________

If yes, date of the seizure: ________________________________________________________________________

3.Has the patient had more than one seizure? ________________________________________________________

4.Does the patient have an electrically diagnosed seizure disorder? _____________________________________

5.Has the patient had an EEG?_________ If yes, date of EEG: __________________________________________

6.Is the patient being treated with medication? _________ If yes, type and dosage:________________________

Does the medication affect the patient's ability to safely operate a motor vehicle? ______________________

7.Other than a seizure disorder, does the patient have episode(s) of loss of consciousness or awareness

that would interfere with the safe operation of a motor vehicle? _______________________________________

If yes, please explain: ____________________________________________________________________________

8.Does the patient have seizure(s) attributable to a prescribed change in or removal from medication? _____

If yes, when was the medication changed/discontinued? ____________________________________________

If yes, date of last seizure: _______________________________________________________________________

Has the original medication been reintroduced? _____________________________________________________

Page 1 of 2

DL-121 (12-12)

PATIENT NAME__________________________________ DRIVER'S LICENSE NUMBER________________

9.Does the patient have seizure(s) always preceded by a specific prolonged aura? __________________________

If yes, what is the duration of the aura? ______________________________________________________________

How is it manifested? ______________________________________________________________________________

Has the patient experienced the aura for at least 2 years? ______________________________________________

10.Does the patient experience only an aura? ___________________________________________________________

How is it manifested? ______________________________________________________________________________

Has the patient experienced only an aura for at least 2 years? __________________________________________

11.Does the patient have a pattern of seizure(s) occurring only during sleep or immediately

upon awakening?__________ Has the patient experienced this pattern for at least 2 years? ________________

12.Were the only seizure(s) the patient had within the last 6 months attributable to a nonrecurring transient

illness, toxic ingestion, or metabolic imbalance? ______________________________________________________

If yes, please explain and include dates of seizure(s): __________________________________________________

_________________________________________________________________________________________________

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

Page 2 of 2

How to Edit Form Dl 121 Online for Free

Any time you need to fill out pa driver's license medical form, you don't have to download any programs - just give a try to our online PDF editor. We at FormsPal are dedicated to providing you with the perfect experience with our tool by regularly introducing new features and enhancements. With these updates, using our editor gets easier than ever! Getting underway is simple! All you have to do is follow the following simple steps below:

Step 1: Just click on the "Get Form Button" in the top section of this page to see our pdf form editing tool. This way, you will find everything that is necessary to fill out your document.

Step 2: As you open the editor, you will find the document all set to be completed. Besides filling out different blank fields, you may as well perform other sorts of things with the form, including writing your own words, changing the original text, inserting graphics, placing your signature to the PDF, and more.

With regards to the fields of this precise PDF, this is what you should do:

1. The pa driver's license medical form necessitates particular details to be inserted. Make certain the subsequent fields are finalized:

Stage number 1 in filling in penndot medical form

2. The next stage is usually to complete all of the following fields: Does the medication affect the, Other than a seizure disorder, that would interfere with the safe, If yes please explain, Does the patient have seizures, If yes when was the medication, If yes date of last seizure, Has the original medication been, and Page of.

Writing part 2 of penndot medical form

3. The following step is about PATIENT NAME DRIVERS LICENSE, Does the patient have seizures, If yes what is the duration of the, How is it manifested, Has the patient experienced the, Does the patient experience only, How is it manifested, and Has the patient experienced only - fill in these empty form fields.

Part # 3 in submitting penndot medical form

4. To go forward, this fourth form section requires completing several form blanks. These comprise of Does the patient have a pattern, upon awakening Has the patient, Were the only seizures the, illness toxic ingestion or, If yes please explain and include, HEALTH CARE PROVIDER INFORMATION, HEALTH CARE PROVIDERS NAME, SPECIALTY, HEALTH CARE PROVIDERS LICENSE, STREET ADDRESS, CITY, STATE, and ZIP CODE, which are integral to moving forward with this particular PDF.

Stage number 4 for filling in penndot medical form

5. This final stage to submit this form is pivotal. Ensure that you fill out the displayed blank fields, for instance TELEPHONE NUMBER, FAX NUMBER, I hereby state that the facts, Health Care Providers Signature, Date, and Page of, before submitting. Failing to do this may contribute to an incomplete and potentially incorrect document!

Guidelines on how to complete penndot medical form part 5

Be extremely mindful when filling in FAX NUMBER and Date, because this is the section where most users make some mistakes.

Step 3: As soon as you have glanced through the details in the blanks, just click "Done" to finalize your FormsPal process. Acquire the pa driver's license medical form when you sign up for a 7-day free trial. Conveniently gain access to the pdf form within your FormsPal account, together with any edits and changes being all kept! FormsPal is dedicated to the personal privacy of all our users; we make certain that all information put into our editor is kept secure.

Form Dl 121 isn’t the one you’re looking for?

Related Documents