Free Medical Examination Report - Wisconsin

MEDICAL EXAMINATION REPORT
MV3644 3/2007

Clear form

Ch. 343 Wis. Stats. & Trans. 112 Admin. Code

APPLICANT: After this medical report has been reviewed, you may be required to file medical reports on a regular basis. We will send you the forms at the time they are required.
Applicant Name Operator License Number

Wisconsin Department of Transportation Medical Review PO Box 7918 Madison WI 53707-7918 Telephone: 608-266-2327 Facsimilie (FAX): 608-267-0518 E-Mail: [email protected]

Street Address

Birth Date

City, State, ZIP Code

Area Code and Telephone Number

Date Issued

Examiner Badge Number

License Type Instruction Permit

Operator

CDLI CDL

Passenger Bus

School Bus

Reason for Referral

Physician/Advanced Practice Nurse Prescriber (APNP): Please complete all pertinent sections relative to this person's health to assist the Department in making a licensing decision. 1. Driver Condition or Behavior Report Attached. Driving Incident/Accident [Date(s)] __________________. 2. General Medical: complete sections A and G (others if appropriate) 3. Mental / Emotional: complete sections A, B, and G 4. Neurological: complete sections A, C, and G 5. Endocrine (Diabetes): complete sections A, D, and G 6. Cardiovascular: complete sections A, E, and G 7. Pulmonary: complete sections A, F, and G SECTION A: Physician/APNP - To Complete for ALL Applicants Provide Diagnoses, Medications Used, and Dosages

Height Yes No

Weight

1. 2. 3. 4. 5.

6. 7.

8.

Is the person's condition currently stable? If not, explain below. Is the person reliable in following the treatment program? If not, explain below. Does this person experience side effects of medication which are likely to impair driving ability? If yes, explain below. Has this person experienced an episode of altered consciousness or loss of bodily control during the past 12 months? If yes, explain below and give date. Does current alcohol/drug abuse/use interfere with medical condition? If yes, a substance evaluation will be required. a. Did the person have a seizure(s) related to withdrawal? If yes, provide date(s) __________________. Does this person experience uncontrolled sleepiness associated with sleep apnea, narcolepsy, or other disorder? If yes, explain below. Is driving ability likely to be impaired by limitations in any of the following? a. Judgment and insight b. Problem-solving and decision-making c. Emotional or behavioral stability d. Cognitive function Is driving ability likely to be impaired by limitations in any of the following? a. Reaction time b. Sensorimotor function c. Strength and endurance d. Range of motion e. Maneuvering skills f. Use of arm(s) and/or leg(s)

Details and Elaboration

Note: Sections B, C and D are on the next page (over). 1

Yes No

SECTION B: MENTAL / EMOTIONAL 1. Has the person been hospitalized in the past year for a mental/emotional condition? If yes, give admission date(s), reason(s) for admission and date(s) of discharge:

2. Does the person have a behavior disorder which is likely to impair driving ability? 3. Identify current treatment program(s), counseling, etc.

SECTION C: NEUROLOGICAL Examining physician: If an episode has occurred in the past 90 days, the examination must be at least 60 days after the episode. 1. Give date of last episode of altered consciousness or loss of bodily control. If last episode occurred within the previous 3 months, the patient is not eligible to hold a license.
Yes No
(Month / Day / Year)

2. Does this person have a seizure disorder? If not, explain cause and/or diagnosis related to episode(s).

3. List anticonvulsant medication: ________________________________ If discontinued, give date: ________________ 4. Was the last medication blood serum level within acceptable range? 5. Does this person's neurological condition involve movement disorder? If yes, please explain. _____________________ 6. If this person holds or is applying for a commerical driver license, and has had an episode of altered consciousness or loss of bodily control since the last report was filed with WDOT, the following is required: a. A narrative summary, including the history of the episode(s); b. An indication of risk for further episodes; c. Current blood levels of anticonvulsant medication; d. Results of the most recent EEG. SECTION D: ENDOCRINE 1. Please provide a hemoglobin A1C reading:
Yes No
(Reading) (Date)

2. Does this person have hypoglycemic reactions? If yes, please explain and provide date of last reaction. 3. Does this person demonstrate how to counter these reactions? 4. Has this person been hospitalized for treatment of diabetes or complications in the past year? If yes, explain below. 5. Indicate type of medication and dosage for current treatment. 6. Is this person experiencing renal failure? If yes, what is their current treatment regimen? _________________________ 7. Does this person monitor his/her blood sugar? 8. Provide the last 3 fasting blood sugar readings and dates recorded. (Home monitoring results ARE acceptable.)
(Reading) (Date) (Reading) (Date) (Reading) (Date)

9. If this person holds or is applying for a commercial license, and is taking insulin as a NEW treatment in the past 2 years, please provide the following information: a. When was this person diagnosed with diabetes? Yes No b. When was insulin first prescribed? ____________________. c. Do any complications or associated conditions exist? If yes, please explain: _________________________________

2

1 . Functional Class

SECTION E: CARDIOVASCULAR

Yes No

I
2. 3.

II

III

IV

Does the person have an implantable cardioverter defibrillator? If yes, give implant date ________________________ Has the unit discharged since the implant? If yes, describe the person's condition at the time and date of discharge.

4.

List all current cardiac symptoms.

Has this person had any of the following? Please explain any yes answers.
Yes No

5.

Cardiovascular surgery and/or other procedures - describe and give date(s) __________________________________

6. 7.

Syncope Fatigue a. With exertion b. At rest 8. Dyspnea 9. Pulmonary symptoms 10. Have any cardiac tests been conducted (exercise stress test, etc.)? If yes, give procedure(s), date(s), results.

Yes No

SECTION F: PULMONARY 1. 2. 3. 4. 5. Pulmonary Disease? If so, what? Continuous Oxygen Use Required? If so, describe treatment regimen and provide number of liters. Dyspnea at rest? Fatigue at rest? Syncope from cough? Please explain cause and resolution.

6. 7.

Provide Pulse Oximetry: Room Air _______________ Oxygen _______________ List Pulmonary Function Test Results

8.

Does the pulmonary disease prevent activities of daily living? If yes, please identify.

Note: Section G is on the next page (over). 3

SECTION G: Physician's/APNP's Recommendations for ALL Applicants Reporting Physician/APNP: This report must be based on an examination conducted WITHIN THE PAST 90 DAYS or since _______________. The Secretary of the Department of Transportation is, by statute, responsible for the driver licensing decision. Your report will be advisory in determining eligibility. Physician's/APNP's signature AND ALL recommendations (Section G) are required for ALL applicants.
Yes No

1. 2. 3. 4. 5. 6.

In your opinion, is this person medically safe to operate a motor vehicle? In your opinion, is this person medically safe to operate a commercial motor vehicle? In your opinion, is this person medically safe to operate a bus and/or school bus? If applicable, I reviewed the attached Driver Condition or Behavior Report. Re-examination by DOT (Vision Screening, Knowledge, Highway Signs and Road Test). Recommended Restrictions: Continuous Oxygen Use Required Daylight Driving Only ______ miles from home Other:

I certify that I have examined this patient. My speciality is: _______________________________ .
Print Name of Reporting Physician

Check One:

MD DO APNP

Patient Examination Date: Month - Day - Year

Signature of Reporting Physician

Professional License Number

Area Code - Office Telephone Number

X Pursuant to Chapter 448.01(5), Wis. Statutes and Trans Ch. 112.02(16), Wis. Admin. Code, this form must be signed by an MD, DO, or APNP.

4

Print