Medical Examination Form Louisiana PDF Details

Medical Examination Form Louisiana is a legal document that must be completed by healthcare professionals in the state of Louisiana. The form is used to provide information to the court system about a patient's medical history and condition. The form must be completed accurately and completely, and it can be used as evidence in legal proceedings. Depending on the circumstances, it may also be required for insurance purposes or other reasons. Completing the Medical Examination Form Louisiana correctly is essential for ensuring that all necessary information is conveyed to those who need it.

The listing includes specifics of the medical examination form louisiana. It might be helpful to know its size, the typical time needed to complete the form, the blanks you'll need to fill in, and so forth.

QuestionAnswer
Form NameMedical Examination Form Louisiana
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameslouisiana life safety forms, la dmv forms, louisiana dmv forms documents, louisiana dmv medical examination form

Form Preview Example

LOUISIANA DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS

OFFICE OF MOTOR VEHICLES

MEDICAL EXAMINATION FORM

P. O. BOX 64886 BATON ROUGE, LA 70896-4886

The bearer of this medical examination form is being required to undergo an examination by a physician. Authority for the requirement is based on laws of the State of Louisiana relating to the issuance of drivers’ licenses. The completed report of examination will be used by the Department of Public Safety and Corrections as a guide in making a final determination on the bearer’s application, which is now pending.

NOTE TO APPLICANT: This medical examination form must be completed by your physician and returned to this office within 30 days from the “DATE ISSUED” indicated below. Failure to comply will result in the suspension of your driving privileges.

1.TO BE COMPLETED BY THE OFFICE OF MOTOR VEHICLES

APPLICANT’S NAME _______________________________________ DOB _______________ R/S_______ D/L#_______________

ADDRESS _____________________________________________ CITY _______________________________________________

DATE ISSUED ______________________ MVCA’S INITIALS _________________ BADGE# ______________ OFFICE# ________

REMARKS: ________________________________________________________________________________________________

__________________________________________________________________________________________________________

APPLICANT FAILED TO COMPLY WITHIN 30 DAYS.

NOTE TO PHYSICIAN: In accordance with the provisions of R. S. 40:1356, a health care provider is exempt from any liability as a result of reporting to the Department of Public Safety and Corrections any visual ability, physical condition, impairment or disability which may impair a person’s ability to exercise ordinary and reasonable control in the operation of a motor vehicle. This form must be completed in its entirety by the physician. Incomplete forms may be rejected and could result in the denial of this applicant’s driving privileges.

2.TO BE COMPLETED BY THE PHYSICIAN

HISTORY

ORTHOPAEDIC HEARING VISION

1.Patient’s Name: ____________________________________________________ Date of Birth: _____________________

2.Does patient have any medical or physical disorders? _________ If yes, list the medical or physical disorders __________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

3.Is patient taking any medication? _________ If yes, list current medication and dosage __________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

4.Has patient had any past surgical procedures? _________ If yes, list the past surgical procedures ___________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

5.Has patient had any illness that could affect the ability to operate a motor vehicle safely? __________ If yes, describe the illness __________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

6.Has patient’s driving privileges ever been withdrawn for a medical or physical disorder? ____________________________

1.What is patient’s visual acuity without corrective lens? Right eye 20/________ Left eye 20/_______ Both eyes 20/_______

2.Are corrective lens worn? ______ If yes, with corrective lens: Right eye 20/ _____ Left eye 20/ _____ Both eyes 20/ _____

3.What are patient’s peripheral vision fields? ________________ Right eye ________________ Left eye _______________

Applicant can recognize and distinguish among traffic control signals and devices showing standard red, green and amber?

Yes No

1.Does the patient have any hearing impairment? _______ If yes, describe the hearing impairment ____________________

__________________________________________________________________________________________________

2.Is a hearing aid worn? _________ If yes, does it give sufficient correction? ______________________________________

1.Does patient have any amputation or skeletal deficits that could interfere with the ability to operate a motor vehicle safely?

_____ If yes, describe the deficits in detail ________________________________________________________________

_________________________________________________________________________________________________

2.Does patient have stiff or frail joints? _______ If yes, describe ________________________________________________

_________________________________________________________________________________________________

3.Does patient have spastic or paralyzed muscles? _______ If yes, describe ______________________________________

_________________________________________________________________________________________________

4.Does patient have any orthopedic appliances or supports? _______ If yes, list any device or support and how long used __

__________________________________________________________________________________________________

5.Does this device provide adequate compensation for operating a motor vehicle safely? ____________________________

NEUROLOGICAL CARDIOPULMONARY

MENTAL

DIABETES

1.Does patient have angina?______ If yes, when does it occur?_____strenuous activity_____normal activity_____at rest_____

2.Does patient have dyspnea?_____If yes, when does it occur?_____strenuous activity_____normal activity_____at rest_____

3.Does patient have syncope?_____if yes, what is the frequency?__________duration___________last occurance_________

4.Does patient have dizziness?______ describe______________________________________________________________

___________________________________________________________________________________________________

5.What is patient’s blood pressure? 1st reading __________________________ 2nd reading __________________________

6.What is patient’s pulse? Rate __________________________________ Rhythm __________________________________

7.Has patient had cardiovascular catheterization or surgery? ______ If yes, describe _________________________________

___________________________________________________________________________________________________

List medications and dosage: ____________________________________________________________________________

1.Does patient have epilepsy? ______If yes, what type of seizures? _________________ Date of last seizure? ____________

Are seizures completely controlled? _______ Is patient under regular medical care? ________________________________

What are the anticonvulsant serum blood levels? ____________________________________________________________

2.Does patient have any signs of Parkinsonism? ______ If yes, describe condition and severity _________________________

___________________________________________________________________________________________________

Is coordination normal? _______ If no, describe _____________________________________________________________

3.Does patient have any neurological disorder? ______ If yes, describe ___________________________________________

List medications and dosage: ____________________________________________________________________________

Is patient reliable in taking medication and following medical regimen? _____________________________________________

1.Does patient have symptoms of any mental disorder? ______ If yes, describe condition and severity at present ___________

___________________________________________________________________________________________________

2.Has patient ever been treated in a mental hospital? _______ If yes, where and when _______________________________

What was diagnosis and cure? __________________________________________________________________________

3.Does patient use alcohol or drugs? ______ If yes, describe usage ______________________________________________

4.Is patient mentally deficient? ______ If yes, what was highest grade attained in school? ________ age at attainment? _____

5.Does patient have sufficient regard for his/her personal safety as well as that of others to operate a motor vehicle safely? Give details _________________________________________________________________________________________

6.Is patient likely to act on sudden impulse without regard for the consequences of his/her behavior? ____________________

Give details _________________________________________________________________________________________

7.On the basis of your examination and/or knowledge of this patient, do you recommend periodic psychiatric examinations? Give details _________________________________________________________________________________________

List medications and dosage: ____________________________________________________________________________

1.Does patient have a history of diabetes? _______ If yes, is insulin taken? ______ is oral medication taken? ______________

2.What are patient’s laboratory studies? recent urine sugars __________________ recent blood sugars __________________

3.Has patient had any occurrences of diabetic coma? ________ If yes, give dates ___________________________________

4.Has patient had any occurrences of insulin shock? ________ If yes, give dates ____________________________________

5.Does patient have associated abnormalities? visual_______renal_______vascular_______neurological_______other______ If yes, describe _______________________________________________________________________________________

6.Does patient have hypoglycemia? _______ If yes, describe treatment ___________________________________________

List medications taken and dosage: _______________________________________________________________________

Is patient reliable in taking diabetes medication? ______________________ Is diabetes controlled? ______________________

3.TO BE SIGNED BY PATIENT

I hereby authorize the examining physician whose signature appears below to release all information and findings contained herein to the Louisiana Department of Public Safety and Corrections. The Louisiana Department of Public Safety and Corrections can release this information to such individuals or groups as may be considered necessary and appropriate to determine my ability to safely operate a motor vehicle.

Date _____________________________________

Signature of Patient _______________________________________________________

4.TO BE COMPLETED, SIGNED AND DATED BY THE PHYSICIAN

PLEASE REFER TO “NOTE TO PHYSICIAN:” on the first page of this form. Are you this patient’s treating physician? _____________

In your opinion, from a medical standpoint, is it safe for this patient to operate a motor vehicle? _______________________________

On the basis of your examination and/or knowledge of this patient, do you recommend periodic medical reports be submitted? _______

If yes, how often?

6 months

1 year

2 years

other__________ Remarks: ________________________________

___________________________________________________________________________________________________________

Physician’s Signature _________________________________________________________ Date ___________________________

Physician’s Printed Name ______________________________________________________ Telephone# _____________________

Physician’s Address __________________________________________________________________________________________

DPSMV 2032 (R 04/04)

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