Outline
The Medical Examination Louisiana form plays a crucial role in the process of obtaining a driver's license in the state. It is designed to assess an applicant's physical and mental fitness to operate a motor vehicle safely. This form must be completed by a licensed physician, who will evaluate various health aspects, including vision, hearing, neurological, and cardiovascular conditions. The examination results guide the Department of Public Safety and Corrections in making informed decisions about the applicant's ability to drive. Applicants must submit the completed form within 30 days of issuance to avoid suspension of their driving privileges. The form also emphasizes the importance of thoroughness; incomplete submissions can lead to denial of driving rights. Additionally, it includes a section for the physician to report any medical conditions that may impair driving abilities, ensuring that public safety remains a priority. Ultimately, this form serves as a safeguard, balancing individual driving rights with the safety of all road users.
Sample - Medical Examination Louisiana Form
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)
Form Information
| Fact Name | Description |
|---|---|
| Issuing Authority | The Louisiana Department of Public Safety & Corrections oversees the Medical Examination Form. |
| Purpose | This form is required for individuals applying for a driver's license to assess their medical fitness to drive. |
| Submission Deadline | The completed form must be returned within 30 days from the date issued to avoid suspension of driving privileges. |
| Governing Law | The requirement for this examination is based on Louisiana Revised Statutes R.S. 40:1356. |
| Physician's Liability | Health care providers are exempt from liability for reporting medical conditions that may impair driving ability. |
| Patient Information | The form requires comprehensive details about the patient's medical history, medications, and physical conditions. |
| Physician's Recommendation | The physician must provide a recommendation regarding the patient's ability to operate a motor vehicle safely. |
Detailed Guide for Filling Out Medical Examination Louisiana
Completing the Medical Examination Louisiana form is essential for your driver's license application. After you fill it out, your physician will review and provide the necessary medical information. Make sure to return the completed form within 30 days to avoid any issues with your driving privileges.
- Write your name in the space provided for the applicant's name.
- Fill in your date of birth (DOB) and driver's license number (D/L#).
- Provide your address and city.
- Enter the date the form is issued.
- Leave the MVCA’s initials, badge number, and office number blank for the office to complete.
- Make any remarks or notes in the designated section if needed.
- Take the form to your physician for them to complete the medical evaluation section.
- Ensure your physician answers all questions about your medical history, medications, and any relevant conditions.
- Confirm that your physician signs and dates the form at the end, including their printed name and contact information.
- Return the completed form to the Louisiana Department of Public Safety and Corrections within 30 days.
Obtain Answers on Medical Examination Louisiana
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What is the purpose of the Medical Examination Louisiana form?
The Medical Examination Louisiana form is required by the Louisiana Department of Public Safety and Corrections for individuals applying for a driver's license. This form must be completed by a physician to assess the applicant's medical fitness to operate a motor vehicle safely. The findings will help determine whether the applicant can be granted driving privileges.
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Who needs to complete this form?
The form must be filled out by a licensed physician who evaluates the applicant's health status. This includes assessing any medical or physical disorders, medications, and other relevant health information that could impact the ability to drive safely.
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What happens if the form is not submitted within the required time frame?
The completed medical examination form must be returned to the Department of Public Safety and Corrections within 30 days from the date it was issued. If the applicant fails to comply, their driving privileges will be suspended, which can significantly impact their ability to drive legally.
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What specific information is required from the physician?
The physician must provide detailed information regarding the applicant's medical history, including:
- Any medical or physical disorders.
- Current medications and dosages.
- Past surgical procedures.
- Illnesses that may affect driving ability.
- Visual and hearing assessments.
- Any neurological, cardiac, or mental health conditions.
- Diabetes management details.
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What if the physician finds that the applicant is unfit to drive?
If the physician determines that the applicant is not medically fit to operate a motor vehicle, they must indicate this on the form. The Department of Public Safety and Corrections will then take this information into account when making their final decision regarding the applicant's driving privileges.
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Are physicians protected from liability when completing this form?
Yes, according to Louisiana law (R. S. 40:1356), healthcare providers are exempt from liability for reporting any visual ability, physical condition, impairment, or disability that could affect a person's ability to drive. This legal protection encourages physicians to provide accurate assessments without fear of legal repercussions.
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What should an applicant do if they have questions about the form?
If applicants have questions regarding the Medical Examination Louisiana form, they should contact the Louisiana Department of Public Safety and Corrections or consult their physician for clarification. It is crucial to ensure that all information is accurately completed to avoid any delays in the application process.
Common mistakes
Filling out the Medical Examination Louisiana form can be a straightforward process, but many people make common mistakes that could lead to delays or complications. One frequent error is failing to complete all sections of the form. Each part of the form is crucial for the Department of Public Safety and Corrections to assess an applicant's fitness to drive. If any section is left blank, it could result in the form being rejected, which can ultimately affect the applicant’s driving privileges.
Another mistake occurs when applicants do not provide accurate medical history. It is vital to disclose all medical conditions, medications, and past surgeries. Incomplete or incorrect information can lead to misunderstandings about the applicant's health status. This lack of transparency may raise concerns about their ability to operate a vehicle safely, leading to potential denial of their application.
Timing is also an important factor. Many applicants fail to submit the completed form within the required 30-day period. The form must be returned promptly to avoid suspension of driving privileges. Applicants should mark their calendars and ensure that their physician completes the examination and submits the form on time.
Additionally, some people overlook the importance of the physician's signature and details. The physician must not only sign the form but also provide their printed name and contact information. Without this, the form may be deemed invalid. This step is essential for verifying the examination and ensuring that the information provided is credible.
Finally, applicants sometimes neglect to review the form before submission. A quick check can catch any errors or omissions that might have been overlooked. Taking a moment to ensure that all information is complete and accurate can save time and prevent unnecessary complications down the road.
Documents used along the form
The Medical Examination Louisiana form is an essential document for individuals applying for or renewing their driver's licenses in Louisiana. It ensures that applicants are medically fit to operate a vehicle safely. However, this form is often accompanied by several other documents that play a vital role in the overall process. Below is a list of related forms and documents that are frequently used alongside the Medical Examination form.
- Driver's License Application: This form collects personal information from the applicant, including name, address, and date of birth. It serves as the initial request for obtaining or renewing a driver's license.
- Vision Screening Form: This document is specifically designed to assess the applicant's vision. It typically includes tests for visual acuity and peripheral vision, which are crucial for safe driving.
- Medical History Questionnaire: This form gathers detailed information about the applicant's medical history, including any chronic conditions or past surgeries that may affect their driving abilities.
- Physician's Statement of Fitness: A separate document where the physician confirms that the applicant is medically fit to drive. It may include specific recommendations based on the examination results.
- Consent for Release of Medical Information: This form allows the physician to share the applicant's medical information with the Department of Public Safety and Corrections, ensuring compliance with privacy laws.
- Vision Correction Verification: If the applicant wears corrective lenses, this document verifies the prescription and ensures that the lenses meet the necessary standards for driving.
- Hearing Evaluation Report: This report assesses the applicant's hearing capabilities, which are important for safe driving, especially in recognizing sirens and other auditory signals.
- Diabetes Management Plan: For applicants with diabetes, this document outlines their treatment plan and ensures that their condition is well-managed, minimizing risks while driving.
- Periodic Medical Review Form: If the physician recommends ongoing evaluations, this form may be used to document future assessments of the applicant's medical fitness over time.
These documents collectively ensure that the applicant is not only compliant with state regulations but also capable of driving safely. Each form serves a specific purpose in evaluating the applicant's health and fitness to operate a vehicle, ultimately protecting both the driver and the public.
Similar forms
- Driver's Medical Examination Form: Similar to the Louisiana Medical Examination form, this document is used in various states to assess a driver's medical fitness. It includes questions about medical history, medications, and physical capabilities, ensuring that individuals can operate a vehicle safely.
- Commercial Driver's License (CDL) Medical Examination Report: This form is required for individuals applying for a CDL. It evaluates a driver's health, focusing on conditions that could impair their ability to drive commercial vehicles, much like the Louisiana form's emphasis on safety and medical history.
- DOT Medical Examination Form: This form is mandated by the Department of Transportation for commercial drivers. It assesses the physical and mental health of drivers, similar to the Louisiana Medical Examination form, ensuring compliance with safety regulations.
- State-Specific Vision and Hearing Test Forms: Many states require separate forms to evaluate vision and hearing capabilities for drivers. These forms share similarities with the Louisiana Medical Examination, as they focus on sensory abilities critical for safe driving.
- Health History Questionnaire for Drivers: This document gathers comprehensive health information from applicants. Like the Louisiana form, it seeks to identify any medical conditions that could affect driving safety, ensuring that only qualified individuals receive licenses.
Dos and Don'ts
When filling out the Medical Examination Louisiana form, there are specific guidelines to follow. Below is a list of dos and don'ts to ensure a smooth process.
- Do ensure the form is completed in its entirety by your physician.
- Do return the completed form within 30 days from the date issued.
- Do provide accurate and truthful information regarding medical history.
- Do list all medications and dosages clearly.
- Do discuss any past surgical procedures with your physician.
- Don't leave any sections of the form blank, as incomplete forms may be rejected.
- Don't forget to sign and date the form before submission.
- Don't provide misleading information about your health conditions.
- Don't ignore the requirement for your physician's signature and printed name.
- Don't delay in submitting the form, as it could lead to suspension of driving privileges.
Misconceptions
Misconceptions about the Medical Examination Louisiana form can lead to confusion and potential issues with driving privileges. Here are ten common misconceptions, along with clarifications:
- Only those with serious medical conditions need this form. Many people believe that only individuals with obvious health issues must complete this form. However, it applies to anyone whose driving ability may be affected by their health, regardless of the severity of their condition.
- The form is optional. Some think that submitting the medical examination form is a choice. In reality, it is a requirement for certain applicants, and failure to submit it can lead to suspension of driving privileges.
- Any physician can complete the form. While most licensed physicians can fill out the form, it is essential that the examining doctor is familiar with the patient's medical history and current health status to provide accurate information.
- The form does not have a submission deadline. Applicants may assume there is no urgency in submitting the form. In fact, it must be returned within 30 days from the date issued to avoid penalties.
- Completing the form guarantees a driver's license. Some individuals believe that filling out the form ensures they will receive their driving privileges. The completed form is only one part of the evaluation process and does not guarantee approval.
- Physicians are liable for their assessments. There is a misconception that physicians can be held liable for reporting a patient's medical condition. However, Louisiana law protects healthcare providers from liability when they report relevant health information.
- Only physical conditions are evaluated. Many think the form only assesses physical health. In fact, it also evaluates mental health, vision, and hearing, ensuring a comprehensive assessment of the applicant's ability to drive safely.
- Once submitted, the form is not revisited. Some applicants believe that once the form is submitted, it is not reviewed again. In reality, the Department of Public Safety and Corrections may revisit the information if there are concerns about the applicant's ability to drive safely.
- The form is the same for all applicants. There is a belief that the medical examination form is standardized for everyone. In truth, specific requirements may vary based on individual health conditions and the physician's assessment.
- Failure to comply has minor consequences. Some may think that not submitting the form will result in a small penalty. In reality, failure to comply can lead to the suspension of driving privileges, which can significantly impact daily life.
Key takeaways
Filling out the Medical Examination Louisiana form is a critical step in ensuring that applicants meet the necessary health requirements to operate a vehicle safely. Here are five key takeaways to keep in mind:
- Timely Submission is Crucial: The completed form must be returned to the Office of Motor Vehicles within 30 days from the date issued. Delays can lead to suspension of driving privileges.
- Comprehensive Completion Required: The physician must fill out the form entirely. Incomplete forms may be rejected, which could deny the applicant's driving privileges.
- Health History Matters: The form requires detailed information regarding the applicant’s medical history, including any disorders, medications, and past surgical procedures that could affect driving ability.
- Visual and Hearing Assessments: The physician must evaluate the applicant's vision and hearing capabilities. This includes visual acuity and any hearing impairments that could impact safe driving.
- Physician’s Responsibility: The examining physician must assess whether it is safe for the applicant to operate a vehicle. Their professional judgment is vital for the applicant’s driving eligibility.
Completing this form accurately and promptly is essential for maintaining driving privileges in Louisiana. Ensure that all sections are filled out and submitted on time to avoid complications.