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Instructions for Completing a Customer Medical Report (MED 2)

Click to view or print a copy of the medical report.

1. FULL LEGAL NAME - Print or type your full legal name.

2. DRIVER’S LICENSE OR SOCIAL SECURITY NUMBER - Write or type your Virginia driver’s license or identification card number, or your social security number.

3-4. STREET ADDRESS, CITY, STATE, ZIP CODE, CITY OR COUNTY OF RESIDENCE - Print or type your complete street (residence) address including your city or county of residence.

5. MAILING ADDRESS, CITY, STATE, ZIP CODE - Print or type your complete mailing address if It is different from your street address.

6. DAYTIME TELEPHONE NUMBER - Write or type your daytime telephone number, including your area code.

7. DATE OF BIRTH - Write or type your date of birth.

8-12. SEX, WEIGHT, HEIGHT, EYE COLOR, HAIR COLOR - Print or type your description.

13. PLEASE DESCRIBE, IN DETAIL, YOUR MEDICAL CONDITION - Print or type a detailed description of your medical condition.

14. DO YOU TAKE PRESCRIBED MEDICATIONS? - Check the YES or the NO box to show whether or not you take prescribed medications.

15. NAME OF MEDICINE, DOSAGE, TIME(S) TAKEN - Print or type the name of all of your prescribed medication, the dosage amount, how often each dose it taken, and when taken during the day.

16. "HAVE YOU EVER EXPERIENCED A BLACKOUT...?" - Check the YES or the NO box to show whether or not you have ever experienced a blackout, seizure, loss of consciousness, or syncope.

If yes, write or type the date of your last episode.

If no, skip to 19.

17. "DID EPISODE RESULT IN A MOTOR VEHICLE ACCIDENT?" - Check the YES or the NO box to show whether or not the episode resulted in a motor vehicle accident?

18. "EXPLAIN WHAT HAPPENED..." - Print or type a description of what happened during the episode.

19. "ARE YOU APPLYING... FOR A CDL... WAIVER OR...VARIANCE?" - Check the YES or the NO box to show whether or not you are applying to DMV for a CDL disability waiver/CDL hazardous materials variance.

20. "I HEREBY AUTHORIZE..." - Print or type the name of the physician that you authorize to complete this report and to provide to DMV the information requested in this report.

21. SIGNATURE, DATE - Write your signature here and write or type the date.

NOTE: Parent or legal guardian must sign for a minor.

Section A: Medical Information

22. "HOW LONG... BEEN PATIENT?" - Write or type the length of time that this person has been your patient.

23. "...LAST EXAMINED BY YOU?" - Write or type the last date you examined this patient.

24. "MAY DMV RELEASE THE INFORMATION...?" - Check the applicable box to indicate whether or not you authorize DMV to release to your patient the information you provide, if the patient requests the information.

25. WHAT IS YOUR DIAGNOSIS? - Print or type your diagnosis of this patient.

26. "IS THERE A SIGNIFICANT... DISORDER?" - Check the applicable box to indicate whether or not the patient has a significant physical or mental disorder.

If yes, provide details of the disorder.

27. "HAS PATIENT BEEN HOSPITALIZED...?" - Check the applicable box to indicate whether or not the patient was ever hospitalized as a result of the above diagnosis.

If yes, give the date(s) of hospitalization, the reason for admittance, and the patient’s mental and/or physical ability when released.

  • NOTE: If patient was hospitalized within the past three months, a copy of the discharge summary must accompany this report.

28. "IS A SEIZURE DISORDER PRESENT?" - Check the applicable box to indicate whether or not the patient has a seizure disorder.

If yes, check the applicable box to indicate if episode was a break through or other type seizure. If you checked OTHER, specify type of seizure. Give date of episode. Check the applicable box to indicate whether or not episode resulted in a motor vehicle accident.

29. "HAS PATIENT HAD A BLACKOUT...?" - Check the applicable box to indicate whether or not patient has ever had a blackout, loss of consciousness, or syncope.

If yes, Check the applicable box to indicate if the episode was due to hypoglycemia or other condition(s). If you checked OTHER, specify the condition(s). Give the date of the episode. Check the applicable box to indicate whether or not the episode resulted in a motor vehicle accident.

30. HISTORY OF PREVIOUS EPISODE(S) - Print or type detailed information of the patient’s history of episodes.

31. "IS PATIENT COMPLYING WITH TREATMENT?" - Check the applicable box to indicate whether or not the patient is complying with the prescribed treatment. Provide information on the patient’s current and past treatment compliance.

32. PLEASE LIST ALL PRESCRIBED MEDICATIONS - Print or type a list of all medications currently prescribed for the patient, the dosage amount, how often each dose should be taken, and when during the day.

33. EEG RESULTS - Print or type the results of the patient’s latest EEG and give the test date.

Authorixed Physician: Complete This Page

34. "... IS PATIENT ... CAPABLE OF OPERATING A MOTOR VEHICLE?" - Check the applicable box to indicate whether or not the patient is, in your opinion, medically capable of operating a motor vehicle.

35. "... PATIENT NEED TO BE RETESTED... ?" - Check the applicable box to indicate whether or not, in your opinion, DMV needs to retest the patient.

If yes, check the applicable box to indicate which test(s) should be administered.

36. "DOES PATIENT REQUIRE ADAPTIVE EQUIPMENT...?" - Check the applicable box to indicate whether or not the patient needs adaptive equipment to safely operate a motor vehicle.

If yes, print or type the equipment that is needed.

37. "...DOES PATIENT NEED DRIVER REHABILITATIVE TRAINING?" - Check the applicable box to indicate whether or not the patient, in your opinion, needs rehabilitative training for driving.

Complete 38, 39, and 40 only if patient is applying to DMV for a commercial driver’s license disability waiver/ hazardous materials variance.

38. "DOES APPLICANT HAVE A MISSING OR IMPAIRED LIMB?" - Check the applicable box to indicate whether or not the patient has a missing or impaired limb.

If yes, print or type a description of any prosthetic or orthotic device used or needed by the patient.

39. "...ARE ADAPTIVE DEVICES NEEDED?" - Check the applicable box to indicate whether or not any adaptive devices are needed before the patient can safely operate a commercial motor vehicle.

If yes, print or type a description of the device(s) needed.

40. "...CAPABLE OF OPERATING A COMMERCIAL MOTOR VEHICLE SAFELY?" - Check the applicable box to indicate whether or not the patient is, in your opinion, capable of safely operating a commercial motor vehicle.

If no, explain concerns regarding the patient’s capability to safely operate a commercial motor vehicle.

Section B: Visual Information to be Completed by Authorized Eye Care Practitioner

41. "WHEN WAS PATIENT LAST EXAMINED...?" - Give the date that you last examined patient.

42. "MAY DMV RELEASE THE INFORMATION...?" - Check the applicable box to indicate whether or not you authorize DMV to release to your patient the information you provide, if the patient requests the information.

43. Visual examination results fields - Enter the results of the latest visual examination you conducted on patient.

44. "DOES PATIENT HAVE ANY VISUAL DEFECTS...?" - Check the applicable box to indicate whether or not, in your opinion, the patient has any visual defects that would affect the safe operation of a motor vehicle.

If yes, explain the defect(s) affect the safe operation of motor vehicle.

45. "...CAPABLE OF OPERATING A MOTOR VEHICLE?" - Check the applicable box to indicate whether or not the patient is, in your opinion, capable of operating a motor vehicle?

46. DOCTOR’S RECOMMENDATION - Check the applicable box(es) to indicate if the patient should drive only during daylight hours, or wear corrective lenses when driving, or both.

Section C: Completed by Physician / Eye Care Practitioner

48. PRINT PHYSICIAN’S NAME - Print or type your full legal name.

49. SIGNATURE - Write your signature and the date.

50. MEDICAL SPECIALTY - Print or type your medical specialty.

51. TELEPHONE NUMBER - Write or type your daytime business telephone number including the area code.

52. BUSINESS ADDRESS, CITY, STATE, ZIP CODE - Print or type your business mailing address, city, state, and zip code.