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Form 430031

(02-12)

Office of Driver Services (Toll Free) 800 - 532-1121


P.O. Box 9204, Des Moines, IA 50306-9204 515 - 244-9124
FAX: 515 - 239-1837
MEDICAL REPORT
Customer No. Date Requested Requested By
* Reason Requested:

Notice To Applicant FILE (DOC98) FORWARD (98DOC) REFERRAL REASON

Under the authority granted the Department by law, a medical report may be requested for licensing when there is reason to believe that a person may have a
physical or mental condition that would interfere with his/her ability to safely operate a motor vehicle. Licensing consideration may be refused until the necessary
information is provided. The applicant is to complete Section A and Section B.

Take these forms to your physician and request Section C & D be completed. This medical report will not be made available to the public unless you give written
authorization naming the people you want to receive the medical information. Payment for any necessary examination and the preparation of this report is the
responsibility of the applicant. All applicable information is required. Failing to provide the information may result in denial/withdrawal of Iowa driving privileges.

When this form is completed, it should be mailed or brought to:

I authorize my physician(s) to disclose medical information to the Iowa Department of Transportation which relates to my fitness to safely
operate a motor vehicle. I understand that this authorization includes permission for the Department to have this information reviewed by the
Medical Advisory Board, if necessary, for the purpose of giving the Department a medical opinion and that this information will be identified by
number only to the consulting Board.
A photocopy or exact reproduction of this authorization, as duly executed, shall have the same force and effect of this original.

Last Name: First Name: Middle Name: Suffix:


Street: City: State: ZIP Code:
DL No.: Date of Birth: Gender: Phone Number:

Signature of license applicant:

In the past 10 years, have you been treated for or experienced any of the following. If answered "yes", describe the condition under "remarks".
Yes No Condition Yes No Condition
Mental or nervious disease or disorder Alcoholism or chemical dependency
Heart Disese Amputation or physical impairment
Stroke or brain injury Disease injury or or operation to either eye
Sleep disorder Dementia or cognitive impairment
Diabetes (If Yes, do you take insulin? Yes No
REMARKS (attach additional sheets as necessary)

Yes No Loss of Conciousness/Loss of Voluntary Control


Any episode(s) of loss or paroxysmal disturbance of consciousness or loss of voluntary control due to but not limited to any of the
following causes: Epilepsy or convulsive seizures; blackout spells; passing out, syncope, excessive sleepiness, diabetic coma,
insulin shock. If answered "yes", you must complete questions 1-7.
1. Type of los of conciousness or loss of voluntary control? 2. The onset of my loss of consciousness/loss of voluntary control
was at __________ years of age.
3. My losses of consciousness/loss of voluntary control have been as 4. My last episode occurred on
frequent as ___________ per day / month (circle one). Date

5. I can I cannot tell I am going to have a loss of 6. My losses of consciousness/loss of voluntary control occur
consciousness/loss of voluntary control. only during sleep anytime
7. I am presently taking the following medication(s) to control my loss of consciousness/loss of voluntary control. If not taking Medication,
write "None".
Medication Dose How Often
______________________________________ ____________________ ______________________________
______________________________________ ____________________ ______________________________
Form 430031
(02-12)

List all other prescribed medication(s) taken that have not already been identified on this report. (attach additional sheets as necessary)
Medication Dose How Often
______________________________________ ____________________ ______________________________
______________________________________ ____________________ ______________________________
______________________________________ ____________________ ______________________________
______________________________________ ____________________ ______________________________

Are all medications taken as prescribed and taken for therapeutic purposes only? Yes No
List all physicians who have treated you during the previous 2 years. (attach additional sheets as necessary)
Name Specialty Condition treated
______________________________________ ____________________ ______________________________
______________________________________ ____________________ ______________________________
______________________________________ ____________________ ______________________________

I certify that the above statements are accurate to the best of my knowledge.
Signature of license applicant: _________________________________________ Date: ______________________

NOTE TO PHYSICIAN: REASON MEDICAL REPORT REQUESTED:

Please complete the parts of Section C that apply for this individual. If you wish to include pertinent information that is not addressed on this
report, please submit the information on a separate sheet. Section D must be filled out completely. Upon request of the applicant, this
information will be made available to the applicant and/or his/her designee(s). Please remember that the Department will require testing (e.g.
written test, driving test, etc.) as necessary and appropriate to determine the applicant's ability to drive. The Department must have the
following medical information to determine the applicant's ability to safely operate a motor vehicle.

Has the patient had any paroxysmal disturbances of consciousness; epilepsy or convulsive seizures; blackout spells; passed out;
syncope of any cause; any type of periodic or episodic loss of consciousness or loss of voluntary control? Yes No

If yes, this section must be filled out completely.

Date of last episode: _________________________ Type of episode: ____________________________________ __


LOSS OF CONSCIOUSNESS or LOSS OF VOLUNTARY CONTROL

Cause of episode: ___________________________ Classification of seizure, if applicable: ______________________

Was this a single episode? Yes No If yes, is the patient likely to experience another episode? Yes No
Is the patient receiving any treatment for the single episode? Yes No

Did the episode occur as a result of physician-supervised medication withdrawal? Yes No


If yes, has patient remained episode-free since being placed back on medication(s)? Yes No

Time of episode(s): only during sleep anytime

History: Age of onset __________

Type of loss of consciousness/loss of voluntary control Frequency of loss of consciousness/loss of voluntary control
___________________________________________________________________________________________________
at onset
________________________________________________________________________________________________________________
subsequently
________________________________________________________________________________________________________________
presently
___________________________________________________________________________________________________

Presence of aura Yes No Type of aura: ___________________________

Electroencephalograph: Date: ___________ Results: _______________________________

Medication: List medication(s) presently given to control loss of consciousness/loss of voluntary control.
Medication Dose
______________________________________ ____________________
______________________________________ ____________________
______________________________________ ____________________
Has the patient used any medications to control episode(s) of loss of consciousness/ loss of voluntary control in the past
24 months? Yes No Date discontinued: _______________
Form 430031
(02-12)

Does the patient have a sleep disorder or health condition that could cause the sudden or immediate onset of sleep?
Yes Please identify the condition: narcolepsy obstructive sleep apnea other ____________________________
SLEEP DISORDER

Date of last instance ______________________________


Is the patient being treated for this condition? Yes No
Type of treatment ________________________________ Date treatment began ____________________________
Is the patient compliant with treatment? Yes No
No If a sleep disorder does not exist and this Medical Report is required because the patient fell asleep while driving, what
caused him/her to fall asleep while driving? _______________________________________________________________
Is this type of episode likely to happen again? Yes No

Diagnosis: Type I Type II Age of onset __________


Controlled by: Diet Insulin injection Insulin pump Oral medication _________________________________
Has the patient had a hypoglycemic episode that resulted in a loss of consciousness or loss of voluntary control? Yes No
If yes, how many times: ______ Date of last episode____________________
Coma Yes No How many times: ______ Date of last coma: _____________________
Insulin shock Yes No How many times: ______ Date of last shock: _____________________
DIABETES

Is the patient likely to experience another episode? Yes No


Is there any warning of impending hypoglycemia, coma, or shock? Yes No
Does the patient have any diabetes related complication(s) that could affect the safe operation of a motor vehicle? Yes No
If yes, list related complications: ______________________________________________________________________________
Has the complication(s) been assessed? Yes No If yes, type of assessment _________________ Date ____________
If further assessment is recommended, what type? _______________________________________________________________
Does the patient have a proper understanding of diabetes and the control of diabetes? Yes No
Is the patient compliant with diabetes therapy? Yes No Degree of control _______________________________________

Diagnosis: Stroke Multiple sclerosis Parkinson's disease Head/spinal cord injury Brain tumor
Dementia/Alzheimer's disease Other _____________
NEUROLOGICAL

Note: If a loss of consciousness or loss of


Is the patient's driving ability likely to be impaired in the following areas? voluntary control episode occurred also
Range of motion Yes No Reaction time Yes No complete the LOSS OF CONSCIOUSNESS / LOSS
OF VOLUNTARY CONTROL section on page 2
Strength/endurance Yes No Cognitive abilities Yes No
List any other limitation that could affect the patient's ability to operate a motor vehicle with safety: _______________________
Has the patient completed a cognitive assessment? Yes No If yes, where? _____________________ Date____________
Do you recommend a cognitive assessment prior to application for a driver's license? Yes No
SUBSTANCE ABUSE
MENTAL DISORDER

Has the patient ever been diagnosed with a mental, nervous, or psychiatric disorder? Yes No
If yes, is the condition likely to interfere with the patient's ability to operate a motor vehicle safely? Yes No
Has the person ever been a patient in or committed to an institution for mental illness? Yes No
If yes, when (date) ____________________ Type of discharge _________________________________________
Has the patient ever been committed to a treatment facility for substance abuse or dependence? Yes No
If yes, which substance(s)? _______________________________ Date of abstinence ________________________

Syncope Yes No If yes, date of last episode ____________ Frequency __________________


Blood pressure _______________ Edema Yes No
RESPIRATORY
CARDIAC

Dyspnea Yes No If yes, at rest slight exertion moderate


Angina Yes No If yes, at rest slight exertion moderate
Dizziness Yes No If yes, at rest slight exertion moderate
Functional capacity AHA Class 1 - No limitation physical activity Class 3 - Marked limitation physical activity
Class 2 - Slight limitation physical activity Class 4 - Complete limitation physical activity
Form 430031
(02-12)

Are there any stiff or flail joints? Yes No If yes, where? __________________________________________________
Are there any spastic or paralyzed muscles? Yes No If yes, where? ________________________________________
Has there been an amputation? Yes No If yes, what portion of the anatomy? _________________________________
Do any of the above interfere with the patient's ability to operate a motor vehicle safely? Yes No
ORTHOPEDIC

Has the patient completed a driving evaluation by an occupational therapist or a driving rehabilitation specialist? Yes No
If yes, where? _________________________ Date _______________
Note: If a driving evaluation by an occupational therapist or a driving rehabilitation specialist is recommended prior to application
for a driver's license, see Section D question 11.
Orthopedic appliances, supports, vehicle modification and assistive devices, if any, necessary for operating a motor vehicle.
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

OTHER CONDITIONS: If you wish to include medical information concerning this patient that is not addressed on this report,
please submit the information on a separate sheet.

EXAMINING PHYSICIAN: THIS SECTION MUST BE FILLED OUT COMPLETELY. If not, your patient's application may be denied and
your patient will be asked to return to you for the requested information.
1. I am this patient's attending physician. Yes No If no, the attending physician is ______________________________
2. I am aware of this patient's medical history. Yes No
3. Is this patient a chronic alcoholic or addicted to narcotic drugs? Yes No If yes, which substance ____________________
4. Please list patient's medication(s) NOT previously listed in Section C. (Attach extra sheet, if necessary)

Medication Medical condition Dose


________________________________ ________________________________ ____________________
________________________________ ________________________________ ____________________
________________________________ ________________________________ ____________________
5. To your knowledge, are all medications taken as prescribed and for therapeutic purposes only? Yes No
6. If medication(s) are taken as prescribed, do they affect this patient's ability to operate a motor vehicle safely? Yes No
If yes, please explain ______________________________________________________________________________

7. Is the patient aware of the impact his/her condition has on the safe operation of a motor vehicle? Yes No
8. Do your findings indicate that this patient is physically qualified to operate a motor vehicle with safety? Yes No
If no, please explain _______________________________________________________________________________

9. Do your findings indicate that this patient is mentally qualified to operate a motor vehicle with safety? Yes No
If no, please explain _______________________________________________________________________________

10. Do you recommend further medical evaluation by a physician specializing in the area of question prior to the issuance of a
driver's license? Yes No If yes, what type of evaluation is needed? _________________________________________
11. Do you recommend a driving evaluation by an occupational therapist or a driving rehabilitation specialist? Yes No
12. Should the department require another Medical Report in
6 months 1 year 2 years Other _____________
No follow-up Medical Report recommended by physician
13. Remarks: _______________________________________________________________________________________________

PLEASE NOTE: For this Medical Report to be considered:


* The date of examination must be within 6 months of application for a license
* The date of examination must be 6 months after the most recent loss of consciousness or loss of voluntary control episode
* The report must be signed by a physician licensed to practice medicine & surgery (M.D.) or osteopathic medicine & surgery (D.O.)

Date of Examination

Licensed physician's name (Please print) Medical license number Specialty Telephone number

Sreet Address City State ZIP Code

Licensed physician's signature Today's date