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The Medical Examination Louisiana form is an essential document required by the Louisiana Department of Public Safety and Corrections for individuals applying for or renewing their driver’s licenses. This form mandates that applicants undergo a medical evaluation by a licensed physician, who will assess various health factors that may impact the applicant's ability to operate a vehicle safely. The examination covers a wide range of areas, including the applicant's medical history, vision, hearing, neurological and cardiovascular health, as well as any mental health considerations. It is crucial for the physician to complete the form thoroughly, as any incomplete sections may lead to the denial of the applicant's driving privileges. Additionally, the form must be submitted within 30 days of issuance to avoid suspension of driving rights. The physician is also protected from liability when reporting any medical conditions that could impair driving abilities, ensuring that the evaluation process prioritizes public safety. By carefully documenting the applicant's health status, this form serves as a vital tool in determining fitness to drive, reflecting the state's commitment to ensuring safe roads for all.
Document Example
LOUISIANA DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF MOTOR VEHICLES
MEDICAL EXAMINATION FORM
P. O. BOX 64886 • BATON ROUGE, LA
The bearer of this medical examination form is being required to undergo an examination by a physician. Authority for the requirement is based on laws of the State of Louisiana relating to the issuance of drivers’ licenses. The completed report of examination will be used by the Department of Public Safety and Corrections as a guide in making a final determination on the bearer’s application, which is now pending.
NOTE TO APPLICANT: This medical examination form must be completed by your physician and returned to this office within 30 days from the “DATE ISSUED” indicated below. Failure to comply will result in the suspension of your driving privileges.
1.TO BE COMPLETED BY THE OFFICE OF MOTOR VEHICLES
APPLICANT’S NAME _______________________________________ DOB _______________ R/S_______ D/L#_______________
ADDRESS _____________________________________________ CITY _______________________________________________
DATE ISSUED ______________________ MVCA’S INITIALS _________________ BADGE# ______________ OFFICE# ________
REMARKS: ________________________________________________________________________________________________
__________________________________________________________________________________________________________
APPLICANT FAILED TO COMPLY WITHIN 30 DAYS.
NOTE TO PHYSICIAN: In accordance with the provisions of R. S. 40:1356, a health care provider is exempt from any liability as a result of reporting to the Department of Public Safety and Corrections any visual ability, physical condition, impairment or disability which may impair a person’s ability to exercise ordinary and reasonable control in the operation of a motor vehicle. This form must be completed in its entirety by the physician. Incomplete forms may be rejected and could result in the denial of this applicant’s driving privileges.
2.TO BE COMPLETED BY THE PHYSICIAN
HISTORY
ORTHOPAEDIC HEARING VISION
1.Patient’s Name: ____________________________________________________ Date of Birth: _____________________
2.Does patient have any medical or physical disorders? _________ If yes, list the medical or physical disorders __________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3.Is patient taking any medication? _________ If yes, list current medication and dosage __________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
4.Has patient had any past surgical procedures? _________ If yes, list the past surgical procedures ___________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
5.Has patient had any illness that could affect the ability to operate a motor vehicle safely? __________ If yes, describe the illness __________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
6.Has patient’s driving privileges ever been withdrawn for a medical or physical disorder? ____________________________
1.What is patient’s visual acuity without corrective lens? Right eye 20/________ Left eye 20/_______ Both eyes 20/_______
2.Are corrective lens worn? ______ If yes, with corrective lens: Right eye 20/ _____ Left eye 20/ _____ Both eyes 20/ _____
3.What are patient’s peripheral vision fields? ________________ Right eye ________________ Left eye _______________
Applicant can recognize and distinguish among traffic control signals and devices showing standard red, green and amber?
□ Yes □ No
1.Does the patient have any hearing impairment? _______ If yes, describe the hearing impairment ____________________
__________________________________________________________________________________________________
2.Is a hearing aid worn? _________ If yes, does it give sufficient correction? ______________________________________
1.Does patient have any amputation or skeletal deficits that could interfere with the ability to operate a motor vehicle safely?
_____ If yes, describe the deficits in detail ________________________________________________________________
_________________________________________________________________________________________________
2.Does patient have stiff or frail joints? _______ If yes, describe ________________________________________________
_________________________________________________________________________________________________
3.Does patient have spastic or paralyzed muscles? _______ If yes, describe ______________________________________
_________________________________________________________________________________________________
4.Does patient have any orthopedic appliances or supports? _______ If yes, list any device or support and how long used __
__________________________________________________________________________________________________
5.Does this device provide adequate compensation for operating a motor vehicle safely? ____________________________
NEUROLOGICAL CARDIOPULMONARY
MENTAL
DIABETES
3.
1.Does patient have angina?______ If yes, when does it occur?_____strenuous activity_____normal activity_____at rest_____
2.Does patient have dyspnea?_____If yes, when does it occur?_____strenuous activity_____normal activity_____at rest_____
3.Does patient have syncope?_____if yes, what is the frequency?__________duration___________last occurance_________
4.Does patient have dizziness?______ describe______________________________________________________________
___________________________________________________________________________________________________
5.What is patient’s blood pressure? 1st reading __________________________ 2nd reading __________________________
6.What is patient’s pulse? Rate __________________________________ Rhythm __________________________________
7.Has patient had cardiovascular catheterization or surgery? ______ If yes, describe _________________________________
___________________________________________________________________________________________________
List medications and dosage: ____________________________________________________________________________
1.Does patient have epilepsy? ______If yes, what type of seizures? _________________ Date of last seizure? ____________
Are seizures completely controlled? _______ Is patient under regular medical care? ________________________________
What are the anticonvulsant serum blood levels? ____________________________________________________________
2.Does patient have any signs of Parkinsonism? ______ If yes, describe condition and severity _________________________
___________________________________________________________________________________________________
Is coordination normal? _______ If no, describe _____________________________________________________________
3.Does patient have any neurological disorder? ______ If yes, describe ___________________________________________
List medications and dosage: ____________________________________________________________________________
Is patient reliable in taking medication and following medical regimen? _____________________________________________
1.Does patient have symptoms of any mental disorder? ______ If yes, describe condition and severity at present ___________
___________________________________________________________________________________________________
2.Has patient ever been treated in a mental hospital? _______ If yes, where and when _______________________________
What was diagnosis and cure? __________________________________________________________________________
3.Does patient use alcohol or drugs? ______ If yes, describe usage ______________________________________________
4.Is patient mentally deficient? ______ If yes, what was highest grade attained in school? ________ age at attainment? _____
5.Does patient have sufficient regard for his/her personal safety as well as that of others to operate a motor vehicle safely? Give details _________________________________________________________________________________________
6.Is patient likely to act on sudden impulse without regard for the consequences of his/her behavior? ____________________
Give details _________________________________________________________________________________________
7.On the basis of your examination and/or knowledge of this patient, do you recommend periodic psychiatric examinations? Give details _________________________________________________________________________________________
List medications and dosage: ____________________________________________________________________________
1.Does patient have a history of diabetes? _______ If yes, is insulin taken? ______ is oral medication taken? ______________
2.What are patient’s laboratory studies? recent urine sugars __________________ recent blood sugars __________________
3.Has patient had any occurrences of diabetic coma? ________ If yes, give dates ___________________________________
4.Has patient had any occurrences of insulin shock? ________ If yes, give dates ____________________________________
5.Does patient have associated abnormalities? visual_______renal_______vascular_______neurological_______other______ If yes, describe _______________________________________________________________________________________
6.Does patient have hypoglycemia? _______ If yes, describe treatment ___________________________________________
List medications taken and dosage: _______________________________________________________________________
Is patient reliable in taking diabetes medication? ______________________ Is diabetes controlled? ______________________
TO BE SIGNED BY PATIENT
I hereby authorize the examining physician whose signature appears below to release all information and findings contained herein to the Louisiana Department of Public Safety and Corrections. The Louisiana Department of Public Safety and Corrections can release this information to such individuals or groups as may be considered necessary and appropriate to determine my ability to safely operate a motor vehicle.
Date _____________________________________ |
Signature of Patient _______________________________________________________ |
4.TO BE COMPLETED, SIGNED AND DATED BY THE PHYSICIAN
PLEASE REFER TO “NOTE TO PHYSICIAN:” on the first page of this form. Are you this patient’s treating physician? _____________
In your opinion, from a medical standpoint, is it safe for this patient to operate a motor vehicle? _______________________________
On the basis of your examination and/or knowledge of this patient, do you recommend periodic medical reports be submitted? _______
If yes, how often? |
6 months |
1 year |
2 years |
other__________ Remarks: ________________________________ |
___________________________________________________________________________________________________________ |
||||
Physician’s Signature _________________________________________________________ Date ___________________________
Physician’s Printed Name ______________________________________________________ Telephone# _____________________
Physician’s Address __________________________________________________________________________________________
DPSMV 2032 (R 04/04)
Dos and Don'ts
When filling out the Medical Examination Louisiana form, it is important to follow specific guidelines to ensure the process goes smoothly. Below are seven recommendations regarding what to do and what to avoid.
- Do ensure that all sections of the form are completed accurately by the physician.
- Do submit the completed form within 30 days from the date issued to avoid suspension of driving privileges.
- Do provide detailed information about any medical conditions or medications that could affect driving ability.
- Do verify that the physician signs and dates the form before submission.
- Don't leave any sections blank, as incomplete forms may be rejected.
- Don't submit the form after the 30-day deadline, as this can lead to a loss of driving privileges.
- Don't withhold any relevant medical history that could impact the assessment of driving safety.
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Detailed Instructions for Filling Out Medical Examination Louisiana
Completing the Medical Examination Louisiana form is essential for your driving privileges. After you fill out the necessary sections, your physician will conduct an examination and provide their findings. Ensure that the completed form is submitted within 30 days to avoid any suspension of your driving privileges.
- Obtain the Medical Examination Louisiana form from the Louisiana Department of Public Safety & Corrections or your physician.
- Fill in your personal information in the section labeled "TO BE COMPLETED BY THE OFFICE OF MOTOR VEHICLES." Include your name, date of birth, driver's license number, and address.
- Write the date the form is issued and any remarks if necessary.
- Take the form to your physician for examination.
- Your physician will complete the "TO BE COMPLETED BY THE PHYSICIAN" section. They will need to provide information about your medical history, medications, and any physical or mental conditions that may affect your driving ability.
- Ensure your physician fills out the visual and hearing assessments, including visual acuity and peripheral vision fields.
- Ask your physician to confirm whether you have any orthopedic, neurological, cardiopulmonary, mental, or diabetes-related issues that could impact your ability to drive safely.
- Sign the section that authorizes the physician to release your information to the Louisiana Department of Public Safety and Corrections.
- Have your physician sign and date the form, providing their printed name and contact information.
- Submit the completed form to the Louisiana Department of Public Safety and Corrections within 30 days of issuance.
Documents used along the form
The Medical Examination Louisiana form is an essential document required for individuals applying for or renewing their driver's licenses in Louisiana. However, it is often accompanied by several other forms and documents that help provide a comprehensive view of the applicant's health and driving capabilities. Here’s a brief overview of six commonly used documents that may accompany the Medical Examination form.
- Driver's License Application: This is the primary form that individuals fill out when applying for a new driver's license or renewing an existing one. It collects personal information, including name, address, and date of birth, and serves as the foundation for the licensing process.
- Vision Screening Form: Often required in conjunction with the Medical Examination, this form specifically assesses the applicant's visual acuity and peripheral vision. It helps determine if the individual meets the minimum vision standards necessary for safe driving.
- Motor Vehicle Power of Attorney: This document empowers an individual to authorize another person to handle specific vehicle transactions on their behalf, ensuring tasks such as buying, selling, or transferring ownership are managed efficiently. For more information, you can visit Fast PDF Templates.
- Medical History Questionnaire: This form gathers detailed information about the applicant's medical history, including past illnesses, surgeries, and current medications. It provides the physician with a broader context for evaluating the applicant's fitness to drive.
- Physician's Statement: A separate document where the examining physician provides their professional opinion on the applicant's ability to operate a motor vehicle safely. This statement may include recommendations for follow-up evaluations or restrictions based on the individual's health.
- Consent for Release of Information: This form allows the applicant to authorize the physician to share their medical information with the Department of Public Safety and Corrections. It ensures that the necessary information is available for evaluating driving eligibility.
- Medical Waiver Form: In some cases, applicants with certain medical conditions may need to submit a waiver form. This document requests an exemption from standard medical requirements based on specific health circumstances, allowing for a more tailored evaluation process.
Each of these forms plays a crucial role in ensuring that individuals are medically fit to drive, thereby promoting safety on the roads. Understanding these documents can help applicants navigate the process more smoothly and enhance their chances of obtaining or retaining their driving privileges.
Your Questions, Answered
What is the purpose of the Medical Examination Louisiana form?
The Medical Examination Louisiana form is required for individuals applying for a driver's license in Louisiana. It serves as a means for the Department of Public Safety and Corrections to assess the applicant's medical fitness to operate a motor vehicle. The completed form provides crucial information about the applicant's health, which aids in determining whether they can safely drive.
Who is responsible for completing the form?
The form must be completed by a licensed physician. It is essential that the physician provides thorough and accurate information regarding the applicant's medical history, current health status, and any conditions that may affect their ability to drive safely.
What happens if the form is not submitted within 30 days?
If the completed form is not returned to the Office of Motor Vehicles within 30 days from the date issued, the applicant's driving privileges will be suspended. Timely submission is crucial to avoid any interruptions in driving rights.
What information does the physician need to provide?
The physician must provide detailed information regarding:
- The applicant's medical history, including any disorders or medications.
- Visual acuity and any corrective measures used.
- Hearing ability and any assistive devices.
- Any physical or neurological conditions that could impair driving.
- Any history of mental health issues or substance use.
Incomplete forms may be rejected, which could jeopardize the applicant's ability to obtain a driver's license.
What should an applicant do if they have a medical condition?
If an applicant has a medical condition that could affect their driving ability, it is vital to disclose this information to the physician. The physician will assess the condition and determine whether it poses a risk when operating a vehicle. Full transparency is essential for ensuring safety on the roads.
Can a physician be held liable for reporting medical conditions?
No, physicians are exempt from liability when reporting a patient's medical condition that may impair their ability to drive. This protection allows healthcare providers to fulfill their duty to ensure public safety without fear of legal repercussions.
Is there a specific format for the physician's signature?
The physician must sign and date the form to validate it. Additionally, they should print their name and provide their contact information. This ensures that the Office of Motor Vehicles can reach out if further information is needed.
What if the applicant disagrees with the physician's assessment?
If an applicant disagrees with the physician's assessment regarding their ability to drive, they should discuss their concerns directly with the physician. It may also be possible to seek a second opinion from another qualified medical professional. However, the final determination will be made by the Department of Public Safety and Corrections based on the submitted medical information.
Common mistakes
Completing the Medical Examination Louisiana form can be a straightforward process, but several common mistakes can lead to delays or complications. One frequent error occurs when applicants fail to provide their full name and date of birth accurately. This information is crucial for identifying the individual and linking the examination results to the correct application. A simple misspelling or omission can cause significant issues.
Another mistake is not adhering to the 30-day submission deadline. The form must be completed by a physician and returned to the Office of Motor Vehicles within this timeframe. If applicants overlook this requirement, they risk having their driving privileges suspended. It’s essential to keep track of the date issued and plan accordingly.
Many applicants also neglect to ensure that the physician fills out the form completely. Incomplete forms may be rejected, which can lead to delays in processing the application. Each section of the form is designed to gather specific information about the applicant’s health, and missing details can hinder the evaluation process.
Inaccuracies in reporting medical history represent another common pitfall. When answering questions about medical or physical disorders, medications, and past surgeries, it’s vital to provide thorough and truthful information. Inconsistencies can raise red flags and may result in the denial of driving privileges.
Applicants often forget to indicate whether they wear corrective lenses. This detail is critical for assessing visual acuity and overall safety while driving. If a patient does wear corrective lenses, the form must reflect their vision with and without these aids accurately.
Another area where mistakes frequently occur is in the section regarding hearing impairments. Applicants sometimes fail to mention the use of hearing aids or other assistive devices. If applicable, detailing the effectiveness of these aids is equally important, as it impacts the overall assessment of the applicant's ability to drive safely.
In the neurological section, individuals may overlook disclosing relevant conditions or medications. This oversight can be particularly concerning if the applicant has a history of seizures or other neurological disorders. Full disclosure helps ensure that the physician can make an informed recommendation regarding the applicant's ability to operate a vehicle.
Applicants sometimes forget to sign the form, which can lead to delays in processing. The signature of the patient is required to authorize the release of medical information to the Department of Public Safety and Corrections. Without this signature, the form cannot be considered valid.
Additionally, the physician must also complete and sign their section of the form. If this step is skipped, the entire application could be rejected. Physicians should carefully review their notes and ensure all questions are answered thoroughly and accurately.
Lastly, applicants may fail to keep a copy of the completed form for their records. Having a copy can be beneficial if any questions arise later regarding the submitted information. It serves as a reference point and can help clarify any potential misunderstandings.
Misconceptions
Misconceptions about the Medical Examination Louisiana form can lead to confusion and potential issues for applicants. Here are seven common misunderstandings:
- 1. The form is optional for all applicants. Many believe that the medical examination is optional. However, it is a requirement for certain applicants based on state laws regarding driver’s licenses.
- 2. Any physician can complete the form. Some assume that any doctor can fill out the form. In reality, the form must be completed by a licensed physician who is familiar with the patient's medical history.
- 3. The form can be submitted after 30 days. There is a misconception that the 30-day submission window is flexible. In fact, failure to submit the completed form within this timeframe will result in the suspension of driving privileges.
- 4. The examination only assesses physical health. Many think the examination focuses solely on physical health. However, it also evaluates mental health, vision, hearing, and other factors that could affect driving ability.
- 5. Incomplete forms will still be accepted. Some believe that submitting an incomplete form is acceptable. This is incorrect, as incomplete forms may be rejected, which can lead to denial of the applicant's driving privileges.
- 6. The physician is liable for reporting health conditions. There is a misconception that physicians can be held liable for reporting a patient's medical conditions. In fact, Louisiana law provides exemptions from liability for healthcare providers who report such information.
- 7. The form is only for new drivers. Many think that only new drivers need to complete this form. However, it can also apply to current drivers whose medical conditions may impair their ability to operate a vehicle safely.
Document Attributes
| Fact Name | Details |
|---|---|
| Governing Laws | The medical examination form is governed by Louisiana Revised Statutes (R.S.) 40:1356. |
| Purpose of the Form | This form is required for individuals applying for a driver's license to ensure they meet medical standards. |
| Submission Deadline | The completed form must be returned within 30 days from the date issued to avoid suspension of driving privileges. |
| Physician's Responsibility | The physician must complete the form entirely; incomplete forms may lead to denial of the applicant's driving privileges. |
| Visual Acuity Assessment | The form requires the physician to evaluate the patient's visual acuity with and without corrective lenses. |
| Hearing Impairment Evaluation | Physicians must assess any hearing impairments and whether corrective devices are used. |
| Medical History | Applicants must disclose any medical or physical disorders that could affect their ability to drive safely. |
| Signatures Required | Both the patient and the physician must sign the form to authorize the release of medical information. |
| Periodic Medical Reports | Physicians may recommend periodic medical reports based on their examination of the patient. |
| Liability Exemption | Under R.S. 40:1356, healthcare providers are exempt from liability when reporting medical conditions affecting driving ability. |