Form P 142N PDF Details

The intersection of neurological health and driving capabilities is a critical concern for public safety. In the State of Connecticut, the P-142N form, a Neurology Medical Report, serves as a vital conduit between the medical community and the Department of Motor Vehicles (DMV). This document, required to be filled out by a licensed physician, undertakes the meticulous task of evaluating an individual's neurological fitness to safely operate a motor vehicle. It involves a comprehensive account of the patient's medical examination, conducted within a 90-day frame prior to submission, aiming to trace any conditions that might impair driving abilities. Through this form, physicians report on the patient's diagnosis, course of treatment, and medication relevance to driving, along with a projection on the patient's ability to understand and manage their condition with respect to vehicle operation. Key components also include the patient's consent for the physician to share this information with the DMV, a detailed history of episodes of altered consciousness, and an assessment of the necessity for further evaluation by specialists. The nuanced approach of the P-142N form underpins the DMV's mission to ensure that drivers on the road are not only legally compliant but medically fit, thereby safeguarding the well-being of the broader community.

QuestionAnswer
Form NameForm P 142N
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesct neurology medical report, eversource medform ct, eversource medical forms, medical form for eversource

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NEUROLOGY MEDICAL REPORT

STATE OF CONNECTICUT

 

P-142N REV. 8-17

 

DEPARTMENT OF MOTOR VEHICLES

 

 

DRIVER SERVICES DIVISION

 

 

ct.gov/dmv

 

MAIL TO: DMV, DRIVER SERVICES DIVISION, 60 STATE STREET, WETHERSFIELD, CT 06161-1013

 

The patient named below has been referred to the DMV Driver Services Division concerning their ability to

Address incident of

operate a motor vehicle safely. This medical report must reflect the results of the licensed physician's

 

personal examination of the patient performed within 90 days of this report being filed. It must be signed by

 

the patient authorizing the physician to release this report and any attachments to DMV.

 

DRIVER'S LICENSE NUMBER

CDL/PS YES NO

I hereby authorize the licensed physician completing and signing this medical report to release such report to DMV along with any other medical information necessary to determine my fitness to operate a motor vehicle safely.

PATIENT'S NAME (Please Print)

(Last)

(First)

PATIENT'S SIGNATURE

X

(Initial)

DATE OF BIRTH

 

 

DATE

TELEPHONE NUMBER

()

PATIENT'S ADDRESS

(Street)

(City)

(State)

(Zip Code)

HOW LONG HAVE YOU BEEN TREATING THIS PATIENT?

DATE OF LAST EXAMINATION

HOW MANY YEARS HAS THIS PATIENT HAD THE CONDITION(S) YOU ARE TREATING? PLEASE PROVIDE A BRIEF DIAGNOSIS, ETIOLOGY, AND PROGNOSIS, INCLUDING DATES AND RESULTS OF EEG SCANS, AND/OR OTHER TEST RESULTS, AS NEEDED.

ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST? PLEASE EXPLAIN:

HISTORY OF EPISODES OF ALTERED CONSCIOUSNESS IN THE PAST TWO YEARS

DATE

1.

2.

TYPE

DATE

TYPE

DATE

TYPE

 

 

 

5.

 

 

3.

 

 

 

4.

 

6.

 

MEDICATIONS (RELEVANT TO MOTOR VEHICLE OPERATION)

DATE OF LAB WORK TYPE/DOSE

1.

2.

BLOOD LEVEL

DATE OF LAB WORK

TYPE/DOSE

BLOOD LEVEL

3.

4.

DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT

PERIODIC REPORTING?

YES

NO

IF YES, PLEASE INDICATE THE CONDITION(S) AND RECOMMEND MONITORING INTERVAL(S):

 

 

 

 

 

 

CONDITION

 

EVERY

MONTHS FOR

YEAR(S)

 

 

 

 

 

 

 

 

CONDITION

 

EVERY

MONTHS FOR

YEAR(S)

 

 

 

 

 

 

 

DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S) WHICH MAY AFFECT HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?

DO YOU BELIEVE THIS PATIENT TAKES MEDICATION AS PRESCRIBED?

DO YOU HAVE REASON TO SUSPECT THIS PATIENT ABUSES ALCOHOL OR MEDICATIONS (INCLUDING ILLICIT DRUGS)?

ARE YOU AWARE OF ANY OTHER RELEVANT MEDICAL OR SURGICAL HISTORY? PLEASE EXPLAIN:

CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR VEHICLE?

YES NO

YES NO

YES NO

YES NO

NOT APPLICABLE

PHYSICIAN'S CERTIFICATION: I certify that I have personally examined the above named person within the 90 days preceding completion of this report. I swear or affirm under penalty of false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, and subject to penalties for perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.

PHYSICIAN'S NAME (Please print or type)

OFFICE ADDRESS (Include Zip Code)

TELEPHONE NUMBER

()

PHYSICIAN'S SIGNATURE

X

PHYSICIAN'S LICENSE NUMBER

PHYSICIAN'S SPECIALTY

DATE REPORT COMPLETED

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