Medical Report 2017

Medical Report

Per 625 ILCS 5/6-908 of the Driver’s License Medical Review Law and 625 ILCS 5/2-123(j), all medical statements or reports received by the Secretary of State shall be confidential. This information will be disclosed only as authorized by the above-referenced statutes as now or hereafter amended.

SECTION I — To be Completed by Driver (Please print or type)

Pursuant to 92 Illinois Administrative Code 1030.16, please complete the following information and sign the medical agreement as a condition of licensure.

Name Driver’s License Number

Street Address Date of Birth Gender Male Female

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).

SECTION II MEDICAL HEALTH — To be Completed by MD/DO and/or Medical Professional (NP/PA)

Per Illinois Administrative Code Title 92, Part 1030, all sections of this report must be completed in its entirety.

DATE OF COMPLETION OF MEDICAL HEALTH SECTION II:

1. 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

(b) Neurological YES NO

(c) Musculoskeletal YES NO

(d) Respiratory YES NO

(e) Seizure YES NO

(f) Diabetes YES NO

(g) Dizzy/Fainting Spell YES NO

(h) Alcohol/Drug Abuse YES NO

(i) Other Medical Condition(s)

*For mental health disorders, please refer to Section III-Mental Health. Section III must be completed if the individual has a MENTAL HEALTH disorder.

3. List all current medications prescribed relating to any condition indicated above in Question #2.

4. No medications prescribed

(continued on back)

PATIENT’S NAME:

5. Current Status of Condition:

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

6. In the past six months, has there been an attack of unconsciousness? YES NO Date of Attack

7. Have there been any attack(s) of unconsciousness since the original incident noted in Question 6? YES NO

Date of Attack(s)

8. If there has been an attack of unconsciousness in the past six months you may provide a recommended time frame to return to driving. Please explain:

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. 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 medications prescribed relating to mental health diagnosis/condition indicated above.

4. No medications prescribed

5. (A) Controlled (B) Not Controlled: will not affect driving (C) Not Controlled Condition: may affect driving

SECTION IV — Additional information, special restrictions, etc.

SECTION V — MD/DO and/or Medical Professional (NP/PA)

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

PLEASE MAINTAIN A COPY OF MEDICAL REPORT FOR YOUR RECORDS.