Medical Report Form PDF Details

Ensuring the safety of all drivers on the road involves a complex interplay of regulations, one of which includes the Medical Report form, a document as critical as it is comprehensive, issued by the Illinois Secretary of State's Driver Services Department. This form serves a fundamental purpose: to ascertain an individual's medical fitness to operate a vehicle safely. It meticulously gathers information, starting with personal details supplied by the driver, encompassing a wide range of medical conditions from cardiovascular to neurological issues, and extending to include essential data on any medications prescribed. Notably, the form delves into the realms of both physical and mental health, requiring detailed assessments from medical professionals. It emphasizes the importance of ongoing medical supervision and underscores the driver’s responsibility to adhere to their treatment plans. The form stands as a testament to the state's commitment to road safety, demanding honest and thorough evaluations to protect the driver and the broader community. With such a rigorous approach, the Medical Report form plays a pivotal role in navigating the complexities of health-related driving eligibility, making it an indispensable tool for maintaining the highest standards of road safety in Illinois.

QuestionAnswer
Form NameMedical Report Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesillinois driver's license re examination form, elodie cheyssac, illinois medical report, medical report pdf

Form Preview Example

OFFICE OF THE SECRETARY OF STATE

DRIVER SERVICES DEPARTMENT

DRIVER ANALYSIS DIVISION 2701 S. DIRKSEN PARKWAY SPRINGFIELD, IL 62723 217-782-7246 www.cyberdriveillinois.com

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).

DATE OF COMPLETION OF MEDICAL HEALTH SECTION II: _____________________________________

1.Required: In your professional opinion, is this individual MEDICALLY FIT to safely operate a motor vehicle?

YES

NO

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).

Mental Health Disorder: YES NO

DATE OF COMPLETION OF MENTAL HEALTH SECTION III: _____________________________________

1.Required: In your professional opinion, is this individual MENTALLY FIT to safely operate a motor vehicle?

YES

NO

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.

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