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Fill Out Your Medical Examination Louisiana Form

The Medical Examination Louisiana form is a document mandated by the State of Louisiana that requires individuals to undergo an assessment by a physician. This evaluation serves to determine the applicant's fitness to operate a motor vehicle safely. It is essential for ensuring that all drivers adhere to health regulations that protect both themselves and others on the road.

To proceed with the application process, it is crucial to complete this form by clicking the button below.

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Fill Out Your Medical Examination Louisiana Form

Article Structure

The Medical Examination Louisiana form, issued by the Louisiana Department of Public Safety & Corrections, serves a vital role in ensuring that individuals applying for a driver's license meet the necessary health standards. This form requires the applicant to undergo a medical evaluation by a licensed physician before their driver's license application can be finalized. Upon completion, the physician must detail any medical history, medications, and physical conditions that may affect the applicant's ability to operate a vehicle safely. It is important to complete this form accurately and return it within 30 days of issuance to avoid any suspension of driving privileges. The evaluation addresses various aspects, including vision, hearing, and neurological health, emphasizing the applicant’s overall fitness to drive. Notably, physicians are protected from liability when reporting any medical issues, which adds a layer of responsibility to the assessment process. By completing this form, applicants not only comply with state requirements but also take an essential step toward ensuring the safety of themselves and others on the road.

Medical Examination Louisiana Example

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

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)

Get Medical Examination Louisiana PDF Form

Form Characteristics

Fact Name	Description
Governing Law	The Medical Examination Form is governed by Louisiana Revised Statutes R.S. 40:1356.
Issuing Authority	This form is issued by the Louisiana Department of Public Safety and Corrections, specifically the Office of Motor Vehicles.
Submission Deadline	The completed form must be returned to the Office of Motor Vehicles within 30 days from the date issued.
Consequences of Non-compliance	If the form is not submitted within the 30-day timeframe, the applicant's driving privileges will be suspended.
Physician Liability	Healthcare providers are exempt from liability when reporting a patient's medical conditions that may impair driving ability.
Required Information	Physicians must complete all sections of the form. Incomplete forms may lead to denial of the applicant's driving privileges.
Patient Authorization	Patients authorize the release of their medical information to the Louisiana Department of Public Safety and Corrections through their signature on the form.
Physical Exam Requirements	The examination must assess vision, hearing, physical disorders, and any medical history that could affect driving ability.
Periodic Evaluation	Physicians can recommend periodic evaluations for patients based on their medical assessments.

Guidelines on Utilizing Medical Examination Louisiana

The following steps will guide you through the process of correctly filling out the Medical Examination form required by the Louisiana Department of Public Safety and Corrections. It is essential to complete this form accurately to avoid any issues with your driving privileges. Ensure that you follow each step carefully, and provide all necessary information as requested.

Obtain the Form: Acquire the Medical Examination form from the Louisiana Department of Public Safety and Corrections or your physician.
Fill Out the Applicant Section: In the section labelled "TO BE COMPLETED BY THE OFFICE OF MOTOR VEHICLES," write down the applicant's name, date of birth, driving license number, address, and the date issued.
Send to Physician: Deliver the form to your physician, ensuring they understand they need to complete the medical evaluation within 30 days.
Complete Medical History: Your physician will fill out their section, addressing any medical or physical disorders and medications. They will also ask about past surgical procedures, illnesses impacting driving ability, and whether there has been a history of driving privilege withdrawal due to health issues.
Vision Testing: The physician will conduct a vision assessment, noting visual acuity, peripheral vision fields, and whether corrective lenses are worn.
Hearing Assessment: The physician will check if there is any hearing impairment and whether a hearing aid is used.
Physical & Neurological Examination: The physician will evaluate for any physical conditions, joint issues, amputations, or neurological disorders that could impair driving.
Mental Health Evaluation: The physician will ask about mental health history, alcohol or drug use, and overall reliability in making safe driving decisions.
Diabetes Assessment: If applicable, the physician will gather information about diabetes management and any relevant symptoms or occurrences related to the condition.
Sign the Form: After completing the evaluations, your physician will authenticate the form with their signature, date, and printed name, including their contact information.
Submission: Return the signed form to the Louisiana Department of Public Safety and Corrections within the specified timeframe to avoid the suspension of driving privileges.

What You Should Know About This Form

What is the Medical Examination Louisiana form used for?

This form is required by the Louisiana Department of Public Safety and Corrections for applicants seeking to obtain or retain driving privileges. It serves to assess the medical fitness of individuals to operate a motor vehicle safely. The completed form is used to guide the decision-making process regarding the applicant's driving application, ensuring adherence to state laws concerning driver health and safety.

Who is responsible for filling out the Medical Examination form?

The form must be completed by a licensed physician. Applicants are required to undergo a thorough medical examination as dictated by the form, which includes various assessments related to vision, hearing, and any medical conditions that may affect their ability to drive. The physician’s insights are crucial, as incomplete forms may lead to rejection, further delaying the applicant's driving privileges.

What happens if the form is not submitted on time?

The completed Medical Examination Louisiana form must be returned within 30 days from the date it is issued. If it is not submitted within this timeframe, the applicant will face suspension of their driving privileges. Compliance with the deadline is essential to avoid interruptions in driving rights and to ensure a smooth continuation of the licensing process.

Are there any consequences for physicians when filling out this form?

Physicians are provided protection under Louisiana law when reporting visual abilities or medical conditions that could impair a patient's driving. This means they are exempt from liability related to their disclosures made in the course of completing the examination. It is important for physicians to provide complete and accurate information to ensure that the applicant's driving capabilities are appropriately assessed.

How does the applicant authorize the release of their medical information?

At the end of the form, the applicant must sign and date a statement authorizing their physician to release all examination findings to the Louisiana Department of Public Safety and Corrections. This ensures that relevant information about their medical condition is shared with the appropriate individuals to evaluate their ability to operate a motor vehicle safely.

Common mistakes

Completing the Medical Examination form for Louisiana can be a straightforward process, but several common mistakes often occur. One significant error is failing to provide complete personal information. The applicant’s name, date of birth, and driver’s license number must be accurate and fully entered. Missing or incorrect information could delay the processing of the application and may even lead to a denial.

Another issue arises when physicians do not fill out their part thoroughly. It is essential for doctors to answer all questions regarding the applicant’s medical history, medications, and any physical or mental impairments. Incomplete forms may be rejected, which is a major setback for those seeking to regain or maintain their driving privileges.

Timing is also critical. An applicant must return the completed form within 30 days from the date issued. A common mistake is waiting until the last minute. If the form is not submitted on time, it will result in the suspension of driving privileges, leading to unnecessary frustration and complications.

Moreover, applicants may overlook signing the authorization section. This section allows the physician to release information to the Louisiana Department of Public Safety and Corrections. Without this signature, the form is considered incomplete, which can cause further delays in processing.

People also frequently misinterpret the medical questions posed on the form. For example, if an applicant has had a medical condition in the past, they may not realize that they need to disclose this information. Being honest and forthcoming not only helps the physician but also ensures that the applicant's driving assessment is accurate.

Lastly, neglecting to check for errors before submission can lead to issues. It is advisable for both the applicant and the physician to review the completed form for mistakes. Simple typos or incorrect responses can have serious consequences on the status of driving privileges. Taking the time to ensure everything is accurate can save everyone involved a great deal of trouble.

Documents used along the form

The Medical Examination Form in Louisiana serves as a vital document ensuring that individuals meet the necessary health standards to operate a motor vehicle. However, it is not the only document required in conjunction with this examination. Various other forms can complement this process, each serving a specific purpose and functioning as part of the broader framework that governs driver safety and public health. Below is a list of such documents.

Driver's License Application: This is the initial form that individuals fill out to apply for a driver's license. It collects essential information such as the applicant’s name, address, and date of birth, and essentially sets the stage for both the Medical Examination Form and the evaluation of the individual's driving capabilities.
Vision Screening Form: This document includes specific tests to evaluate the applicant's visual acuity and peripheral vision. The results help determine if the individual meets the vision requirements to safely operate a motor vehicle.
Hearing Evaluation Report: Similar to the vision screening, this report verifies that the applicant’s auditory capabilities are sufficient for safe driving. Hearing is vital for recognizing sirens, honking horns, and other important auditory signals on the road.
Physician’s Report of Medical History: This detailed report outlines the individual's complete medical history, offering insights into past disorders, surgeries, and ongoing medications. This information is crucial for assessing any medical conditions that could impair driving ability.
Notice of Suspension: In cases where individuals fail to comply with the medical examination requirements, this document formally notifies them of the suspension of their driving privileges. It is essential for understanding the consequences of non-compliance.
Reinstatement Application: Should an individual's license be suspended due to a medical condition, this form is submitted to request the reinstatement of their driving privileges after meeting the necessary medical criteria.
Disclosure Consent Form: This document allows the physician to share the medical examination results and any related findings with the Department of Public Safety and Corrections. Consent is crucial for maintaining patient privacy while ensuring safety regulations are met.

These forms collectively contribute to a comprehensive assessment of an individual’s ability to drive safely. Understanding the purpose of each document can aid applicants in navigating the often complex landscape of regulations surrounding driver health and safety.

Similar forms

DOT Medical Examination Form: Similar to the Louisiana Medical Examination Form, this document is required for commercial drivers. It mandates a thorough health check to ensure drivers can operate their vehicles safely, focusing on both physical and mental health, similar to the rigorous evaluations outlined in the Louisiana form.
State Driver's License Medical Evaluation Form: Many states have their versions of medical evaluation forms similar to Louisiana's. They require applicants to submit a comprehensive medical history and undergo evaluations, which ultimately determine the approval of their driver’s licenses.
Physical Fitness Certificate: This document is often requested by employers for safety-sensitive positions. Much like the Louisiana form, it assesses an individual's overall health status and ability to perform tasks required by their job, particularly in driving roles.
Insurance Medical Examination Report: Required by some insurance companies when underwriting certain policies, this report collects medical information and evaluates an applicant’s risk level. Similar to the Louisiana medical examination, it supports decision-making about safety and operational capability.
Pre-Employment Medical Assessment: Used by employers in various industries, this assessment ensures prospective employees are fit for duty. It closely mirrors the Louisiana Medical Examination Form in its purpose to identify any potential health issues that could impair an employee's ability to perform their job safely.

Dos and Don'ts

When completing the Medical Examination Louisiana form, it is important to follow certain guidelines to ensure the process goes smoothly. Below is a list of things you should and shouldn't do.

Review the entire form before beginning. Familiarize yourself with the questions and sections that need to be completed.
Provide accurate personal information, including your name, date of birth, and address, as these are essential for identification.
Ensure timely submission. Return the completed form to the office within 30 days of the date issued to avoid any suspension of driving privileges.
Have your physician complete all sections of the form. Incomplete forms may be rejected.
Clearly list all medical conditions and medications you are currently taking. This includes dosage information.

Do not forge signatures or submit a form that is not signed by your physician. Authenticity is crucial.
Do not omit details about past medical procedures or surgeries. Full disclosure is necessary for an accurate evaluation.
Do not ignore important questions regarding your medical history or current physical condition; these are significant for determining your eligibility to drive safely.
Do not take the form lightly. Understand that providing false information can affect your driving privileges.
Do not delay in seeking an appointment with your physician to complete the examination. Waiting until the last minute can lead to rushed submissions or errors.

Following these guidelines will help ensure a clear and efficient process while filling out the Medical Examination Louisiana form.

Misconceptions

Misconception 1: The form is optional.

Some individuals believe that completing the Medical Examination Louisiana form is merely a suggestion. This is incorrect. It is a requirement for applicants with certain medical conditions to undergo a medical evaluation. Failure to submit this form can lead to the suspension of driving privileges.

Misconception 2: Any physician can fill out the form.

While it may seem that any medical doctor can complete the Medical Examination Louisiana form, it is specifically designed to be filled out by a physician familiar with the patient's medical history. Not all healthcare providers may have the necessary understanding of the specific requirements related to driving safety.

Misconception 3: The medical exam is only about vision.

Some people think the examination focuses solely on visual acuity. However, the form covers a wide range of health factors, including neurological, cardiovascular, and mental health assessments. Each section must be addressed to ensure a comprehensive evaluation of the applicant's fitness to drive.

Misconception 4: A completed form guarantees driving privileges.

Submitting a completed Medical Examination Louisiana form does not automatically grant an applicant their driving privileges. The Department of Public Safety and Corrections uses this form to assess whether the individual is fit to operate a vehicle. A favorable examination does not mean the application will be approved unless all other requirements are met.

Key takeaways

Understanding the Medical Examination Louisiana Form is crucial for both applicants and physicians involved in the process. Here are some key takeaways regarding its completion and submission:

The form is required for individuals applying for a driver's license in Louisiana, indicating that a physician's assessment is necessary.
It must be completed by a licensed physician. If the form is incomplete, it may be rejected, leading to potential denial of driving privileges.
Applicants are given a strict timeline: the physician must return the completed form within 30 days from the date issued. Timeliness is essential to avoid suspension of driving privileges.
The physician must provide detailed information about the applicant’s medical history, including any disabilities or conditions that might impact driving ability.
Visual acuity and any necessary corrective lenses must be documented accurately to assess the applicant’s driving capabilities.
Any mental health concerns should be addressed thoroughly, as these can greatly influence safety on the road.
The physician must sign and date the form, confirming their assessment, including recommendations for ongoing evaluations if needed.

Following these guidelines ensures that both the applicant and the physician maintain clarity and compliance with state regulations. This fosters a safer driving environment for everyone on the road.

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