The Medical Examination Louisiana form is a document required by the Louisiana Department of Public Safety and Corrections for individuals applying for a driver's license. This form mandates that applicants undergo a medical examination by a licensed physician, ensuring they are fit to operate a vehicle safely. It is crucial to complete and submit this form within 30 days to avoid suspension of driving privileges.
To fill out the Medical Examination Louisiana form, please click the button below.
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Completing the Medical Examination Louisiana form is essential for those required to undergo a medical evaluation to maintain their driving privileges. The form needs to be filled out by a physician and submitted within 30 days of issuance. Ensure all sections are completed accurately to avoid delays or complications with your driving application.
LOUISIANA DEPARTMENT OF PUBLIC SAFETY & CORRECTIONS
OFFICE OF MOTOR VEHICLES
MEDICAL EXAMINATION FORM
P. O. BOX 64886 • BATON ROUGE, LA 70896-4886
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 ___________________________________________
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 _________________________________________________________________________________________
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)
Understanding the Medical Examination Louisiana form can be challenging. Here are seven common misconceptions about this form, along with clarifications to help clear things up.
The Medical Examination Louisiana form is an essential document for individuals applying for a driver's license in Louisiana, as it assesses their physical and mental ability to operate a vehicle safely. Along with this form, several other documents may be required or beneficial during the application process. Below is a list of commonly used forms and documents that complement the Medical Examination Louisiana form.
Being prepared with these additional forms can streamline the application process and help ensure that all necessary information is provided. Applicants are encouraged to check with the Louisiana Department of Public Safety for any specific requirements related to their situation.