Functional Ability Medical Report Form – Fill Out and Use This PDF

Fax Number: (801) 957-8698

_______________________________________________________________________________________________________________________________________

Last Name

First Name

Middle or Maiden Name

Date of Birth

Driver License or DPC #

By signing this form, I authorize my healthcare professional(s) to disclose specific health information regarding my physical, mental and emotional condition relevant to my ability to safely operate a motor vehicle, to the Utah Driver License Division.

I understand that if I fail to sign this authorization my driving privilege may be affected. I understand that this information will be classified as a private record in accordance with GRAMA (UCA 63G-2-202). Individuals who are entitled to have a “private” record disclosed to them are limited to the subject of the record, a parent or legal guardian of an unemancipated minor or legally incapacitated individual, an individual with power of attorney or a notarized release signed by the subject of the record, or an individual with a court or legislative subpoena.

APPLICANT’S SIGNATURE:_______________________________________________________________ Date:___________________________

Form will not be processed without signature

BOTTOM PORTION TO BE COMPLETED AND SIGNED BY HEALTH CARE PROFESSIONAL

The following safety assessment level is for use in determining driving privileges. It is consistent with the current edition of Functional

Ability in Driving: Guidelines and Standards for Health Care Professionals. Please indicate level below with a check mark and your initials .

Safety

Assessment

Level

A

B

C

D

E

F

G

H

J

K

L

Diabetes

Cardio-

Pulmonary

Neurologic

Seizures

Learning

Psychiatric

Alcohol

Musculo-

Alertness

□ Hearing

&

Vascular

□ Inhaler

or

Memory

or

&

skeletal/

or

Metabolic

&

Episodic

Emotional

Other

Chronic

Sleep

Condition

High

Only

Conditions

Condition

Drugs

Debility

Disorders

□ Balance

□ Oxygen

On Insulin

Blood

□ Date of

□ Yes

Pressure

w/Driving

last seizure

□ No

_________:

1

2

3

4

5

N/A

6

N/A

N/A

N/A

N/A

N/A

7

N/A

8

Please indicate if any of the following apply to this medical review:

Recommended Restrictions:

□ Non-standard review time frame_____________________________

□ ADD

OR

□ REMOVE

□ Safety Assessment categories not marked are relevant and should be completed by

□ Speed-posted 40 mph or less

□ Area

another health care professional. Please list categories which are of concern:

□ Oxygen while driving

□ Daylight only

_____________________________________________________________

□I recommend this driver complete a driving skills test in an appropriate vehicle. (Drive test is not available for level 8)

________________________________________________________________________________________________________________________________________

Date form is completed	Printed Name of Health Care Professional and Degree	Signature & initials	State License Number
(Must be submitted to Driver License within 6 months)

________________________________________________________________________________________________________________________________________

Street AddressCity State Zip CodeTelephoneFax Number

Doctor’s Comments________________________________________________________________________________________________________________________________________

□There are special considerations I would like to discuss with a representative of the Division.

________________________________________________________________________________________________________________________________________

Date form is completed	Printed Name of Health Care Professional and Degree	Signature & initials	State License Number
(Must be submitted to Driver License within 6 months)

________________________________________________________________________________________________________________________________________

Street AddressCity State Zip CodeTelephoneFax Number

Doctor’s Comments_______________________________________________________________________________________________________________________

□There are special considerations I would like to discuss with a representative of the Division.

	For more information regarding the medical program or to view current medical guidelines, please visit:
DLD 134 Rev. 11-15	www.driverlicense.utah.gov