Medical Report Form – Fill Out and Use This PDF

Medical Report

Please see guidelines at www.cyberdriveillinois.com, search for Medical/Vision Conditions for completion of form.

SECTION I — To be completed by driver. (Please print or type.)

Name: ___________________________________________________			Driver’s License Number: _________________________________
Last	First	Middle

Street Address: ________________________________________ Date of Birth: _______________________ Gender: ■ Male ■ Female

Month Day Year

City: ___________________________________________________________________________ ZIP Code: ________________________

Agreement/Release of Information

I agree to remain under the care of my physician and follow the treatment exactly as prescribed. I hereby authorize and request my physician to release information regarding my medical condition to the Illinois Secretary of State, and to report any change in the status of my condition that would impair my ability to safely operate a motor vehicle. I understand that failure to abide by the conditions set forth in this agreement are grounds for the Secretary of State to deny or cancel my driving privileges. This report shall remain valid for three months (90 days).

__________________________________________________	__________________________________________________
Signature of Individual	Date of Signature

SECTION II MEDICAL HEALTH — To be completed by MD/DO and/or medical professional (NP/PA).

2.Conditions: Yes or No required for each condition listed.

(a) Cardiovascular	YES	■	NO	■	(provide condition)_______________________________________________
(b) Neurological	YES	■	NO	■	(provide condition)_______________________________________________
(c) Musculoskeletal	YES	■	NO	■	(provide condition)_______________________________________________
(d) Respiratory	YES	■	NO	■	(provide condition)_______________________________________________
(e) Seizure	YES	■	NO	■	(provide condition)_______________________________________________
(f) Diabetes	YES	■	NO	■
(g) Dizzy/Fainting Spell	YES	■	NO	■
(h) Alcohol/Drug Abuse	YES	■	NO	■
(i) Other Medical Condition(s)					(provide condition)_______________________________________________

*For mental health disorders, please refer to Section III-Mental Health.

3.List all current medications. (If medications are listed, a condition must be disclosed above in Question #2.) _____________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

4.■ No medications prescribed.

5.Required: Current Status of Condition:

(A) Controlled ■(B) Not Controlled: will not affect driving ■(C) Not Controlled: may affect driving ■

(If Not Controlled is marked, you must provide details, which may include pertinent clinical information, i.e., test results, lab values.)

_______________________________________________________________________________________________________________

(continued on back) Printed by authority of the State of Illinois. January 2019 - 27.5M - DSD DC-163.8

PATIENT’S NAME: ________________________________________________

6.Required: In the past six months, has the driver’s ability to safely operate a motor vehicle been impaired (due to any reason) or has

driver experienced an attack of unconsciousness?

YES ■

NO ■

Date of Attack: ___________________

(If YES, you must provide details, which may include pertinent clinical information.)

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

7.Date of last impaired ability to safely operate a motor vehicle or attack of unconsciousness. Date: ___________________

(You must provide details, which may include pertinent clinical information.)

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

SECTION III MENTAL HEALTH — To be completed ONLY if driver has a Mental Health Disorder marked “YES” by MD/DO and/or medical professional (NP/PA).

2.Mental Health Disorder Diagnosis/Condition(s): _____________________________________________________________________

3.List all current mental health medications. (If medications are listed, a condition must be disclosed above in Question #2.)

_______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________

4.■ No medications prescribed.

5. (A) Controlled ■

(B) Not Controlled: will not affect driving ■

(C) Not Controlled: may affect driving ■

(If Not Controlled is marked, you must provide details, which may include pertinent clinical information, i.e., test results, lab values.)

_______________________________________________________________________________________________________________

SECTION IV — Additional information, special restrictions, etc.

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

___________________________________________________________________________________________________________________

SECTION V — MD/DO and/or medical professional (NP/PA) — Failure to provide license information will result in return of form to the driver.

(Unacceptable Signatures: Chiropractors, Podiatrists, Residents, Fellows, Interns, RN’s, LPN’s, Co-signatures)

MEDICAL:
______________________________________________________	_______________________________________________________
Provider Name (PRINTED)	Medical Provider’s Address (PRINTED/STAMPED)
______________________________________________________	(	)
	_______________________________________________________
Professional License Number/State License Issued	Telephone Number
______________________________________________________	_______________________________________________________
Provider’s SIGNATURE — Date of Completion	■ MD	■ DO	■ NP ■ PA Provider’s Specialty
MENTAL:
______________________________________________________	_______________________________________________________
Provider Name (PRINTED)	Medical Provider’s Address (PRINTED/STAMPED)
______________________________________________________	(	)
	_______________________________________________________
Professional License Number/State License Issued	Telephone Number
______________________________________________________	_______________________________________________________
Provider’s SIGNATURE — Date of Completion	■ MD	■ DO	■ NP ■ PA Provider’s Specialty

PLEASE MAINTAIN A COPY FOR YOUR RECORDS.