Customer Medical Report
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Is the patient compliant with treatment Does the patient experience side effects of medications, which are likely to impair driving ability Based on this examination, is the patient medically capable of: YES NO ▪ safely operating a motor vehicle YES NO ▪ safely operating a motorcycle YES YES NO If No, explain: NO If Yes, explain: ▪ safely operating a commercial motor vehicle includes tractor trailers, passenger buses, tank vehicles, school buses for 16 or more occupants (including the driver), or vehicles carrying hazardous materials YES NO Based on this examination, patient needs the following: (check each appropriate item) to be retested by DMV on Knowledge Road Both an adaptive device/equipment required to safely operate a motor vehicle.. Based on this examination, the patient s driving ability is likely to be impaired by limitations in the following areas: (check each appropriate item) Judgment and Insight Problem Solving and Decision Making Cognitive Function Emotional or Behavioral Stability Sensorimotor Function Strength and Endurance Reaction Time ADDITIONAL RECOMMENDED RESTRICTIONS MEDICATIONS PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER NAME (print) MEDICAL SPECIALTY MEDICAL LICENSE NUMBER Maneuvering Skills Range of Motion Use of Arm(s) and/or Leg(s) TELEPHONE NUMBER EXPIRATION DATE (mm/dd/yyyy) ISSUING STATE ( FAX NUMBER ) ( ) DATE (mm/dd/yyyy) PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER SIGNATURE If you have questions or need more information to complete this page, call Medical Review Services (804) 367- 6203.. Is the patient compliant with treatment Does the patient experience side effects of medications, which are likely to impair driving ability Based on this examination, is the patient medically capable of: YES NO ▪ safely operating a motor vehicle YES NO ▪ safely operating a motorcycle YES YES NO If No, explain: NO If Yes, explain: ▪ safely operating a commercial motor vehicle includes tractor trailers, passenger buses, tank vehicles, sch
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