The Medical Examination Louisiana form, issued by the Louisiana Department of Public Safety & Corrections, Office of Motor Vehicles, is a crucial document that mandates a physician's comprehensive evaluation of an individual applying for or renewing their driver's license. This form assesses various health aspects, including vision, hearing, physical disorders, and any medications or conditions that might impair the ability to safely operate a motor vehicle, and its completion is essential for the continuation of driving privileges. For those needing to fulfill this requirement, take prompt action to complete and return the form to avoid the suspension of your driving privileges by clicking the button below.
Navigating through the highways of Louisiana necessitates more than just a knowledge of the roads; it requires an assurance that every driver behind the wheel is medically fit to ensure the safety of all. Enter the Medical Examination Louisiana Form, a crucial document administered by the Louisiana Department of Public Safety & Corrections, specifically through the Office of Motor Vehicles. Crafted to safeguard the well-being of the state's motorists, this form stands as a pivotal step for those whose medical conditions might influence their driving capabilities. Prospective drivers are subject to a thorough medical evaluation by a licensed physician, ensuring they meet the necessary health standards to take the wheel. Key aspects of this evaluation include the assessment of vision, hearing, neurological health, and any physical or mental conditions that could impair driving. Significantly, the form also serves a legal function, embodying the state's commitment to road safety through its requirements. With sections meticulously designed for office use, physician completion, and patient consent, the form not only gauges an individual's current health status but also identifies any potential risks on the horizon. Failure to comply with this regulation, especially returning the completed form within a stipulated 30-day window, could lead to the suspension of driving privileges, highlight the form's integral role in both public health and safety.
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)
After receiving the Medical Examination Form from the Louisiana Department of Public Safety & Corrections, Office of Motor Vehicles, individuals are required to complete the form meticulously to ensure the continuation of their driving privileges. The form serves as an essential document for evaluating an applicant's physical and mental fitness for operating a vehicle safely. A licensed physician must perform the examination and fill out the necessary sections. To avoid suspension of driving privileges, the completed form must be returned to the Office of Motor Vehicles within 30 days from the issued date. Below are step-by-step instructions to guide you through the process.
Upon completing the form, it should be reviewed for accuracy and completeness to avoid any delays or denial of your application. Then, following the guidelines set by the Louisiana Department of Public Colorado Safety & Corrections, Office of Motor Vehicles, submit the form within the specified timeframe. Failing to comply with these instructions may result in the suspension of driving privileges, underscoring the importance of timely and accurate form submission.
The Medical Examination Form is used to assess an individual’s physical and mental capabilities to safely operate a motor vehicle. It's a way for the state to ensure that drivers have the necessary physical and mental health to drive without posing a risk to themselves or others. The form must be completed by a physician and submitted to the Department for review as part of the process for issuing or maintaining a driver’s license.
Any driver whose ability to safely operate a vehicle is in question because of physical or mental conditions may be required to submit this form. This determination is made based on state laws and regulations, and those affected will be notified by the Louisiana Office of Motor Vehicles (OMV) that they need to undergo a medical examination.
If the medical examination form is not completed by a physician and returned to the Office of Motor Vehicles within 30 days from the date it was issued, the individual's driving privileges will be suspended. Prompt submission of the completed form is crucial to avoid this outcome.
The form requires detailed information from the physician, including:
No, pursuant to R.S. 40:1356, health care providers are exempt from liability when reporting to the Department of Public Safety and Corrections about a patient’s visual ability, physical condition, impairment, or disability that may impair their ability to operate a motor vehicle safely. This provision encourages physicians to provide accurate and honest assessments without the fear of legal repercussions.
After the form is completed and submitted by the physician, it is reviewed by the Louisiana Department of Public Safety & Corrections. The information provided will guide the Department in making a final decision regarding the applicant's driving privileges. Depending on the findings, the Department may require further evaluations, impose restrictions on the driver's license, or take other appropriate actions to ensure public safety on the roads.
Filling out the Medical Examination form for the Louisiana Department of Public Safety & Corrections can be a straightforward process, but sometimes mistakes happen. Whether it's the rush to meet deadlines or simple oversight, these errors can hold up your application, affecting your driving privileges. Let's go through six common mistakes folks often make with this form:
By avoiding these mistakes, applicants can streamline their process, ensuring their driving privileges are assessed fairly and accurately. Let’s make sure to give this form the care and attention it deserves, for safety’s sake!
In navigating the procedural course toward ensuring an individual can safely operate a motor vehicle in Louisiana, the Medical Examination Louisiana form stands as a crucial document. However, it does not float alone in the sea of documentation necessary for such a determination. Several other forms and documents often accompany it, forming a comprehensive collection that aids in assessing an applicant's capability from various angles.
Each of these documents plays a vital role in piecing together a comprehensive view of an applicant's health and functional capabilities in relation to driving. Together with the Medical Examination Louisiana form, they provide a multi-faceted analysis, ensuring that individuals who receive clearance for driving are competent to do so, safeguarding not only their well-being but also that of the public on Louisiana's roads.
The Medical Examination Louisiana form is similar to various other documentation processes required by governmental and non-governmental entities to ensure public safety and individual well-being. Below are examples of other forms and documents that share similarities with the Medical Examination Louisiana form, detailing how these parallels manifest in their structure and purpose.
One similar document is the Federal Aviation Administration (FAA) Medical Certificate. Like the Louisiana form, the FAA Medical Certificate requires a thorough examination to ascertain an individual’s fitness, in this case, for operating aircraft. Both documents necessitate a healthcare professional's evaluation of vision, hearing, neurological conditions, and cardiovascular health. Furthermore, they both aim to protect public safety by ensuring that only individuals who meet specific health criteria are permitted to operate potentially dangerous vehicles, whether they are cars or aircraft.
Another document with resemblances is the Commercial Driver’s License (CDL) Medical Exam form, mandated by the Department of Transportation (DOT). Similar to the Louisiana form, the CDL Medical Exam requires evaluation by a certified medical examiner and covers extensive ground on the applicant's health, including but not limited to history of medical conditions, vision and hearing tests, and overall physical examination. Both forms serve a regulatory function meant to ensure that individuals in control of large or commercial vehicles are medically fit, thus safeguarding other road users.
The Pre-Employment Physical Examination forms used by many employers also share common features with the Louisiana form. These examinations assess an applicant’s ability to perform job-related duties safely and effectively. Like the Medical Examination Louisiana form, pre-employment physicals may examine an individual's general medical condition, check for physical or mental impairments, and other health assessments critical to the role they’re applying for. The underlying similarity lies in their purpose to ensure that an individual’s health status does not impede their performance and to prevent workplace accidents.
In essence, the Medical Examination Louisiana form is part of a broader spectrum of health evaluation documents utilized in various contexts to ensure individuals meet specific health standards necessary for safe participation in certain activities, occupations, or use of services. Each document, while tailored to its unique domain, shares the common goal of promoting safety and well-being through comprehensive health assessments.
When filling out the Medical Examination Louisiana form, it is important to approach the task with thoroughness and accuracy. Below are the key things you should and shouldn't do to ensure the form is completed correctly:
By adhering to these guidelines, applicants and physicians can contribute to a smoother processing of the Medical Examination Form in Louisiana, thereby helping applicants maintain or regain their driving privileges as efficiently as possible.
Many people have misconceptions regarding the Medical Examination Louisiana form, which can lead to confusion and sometimes, non-compliance. Here are five common misconceptions and the truth behind them:
Understanding these aspects of the Medical Examination Louisiana form helps in appreciating the purpose behind medical evaluations for drivers. It’s all about balancing individual rights with the collective safety of all road users.
Filling out and using the Medical Examination Louisiana form correctly is important for maintaining your driving privileges. Here are 6 key takeaways to ensure the process is smooth and efficient:
Accurate and thorough completion of the Medical Examination Louisiana form is crucial for both the applicant’s safety and compliance with state regulations. It's essential for applicants to discuss any concerns or questions with their physician during the examination to ensure all sections of the form are completed correctly.
La Wage - For detailed excess wage calculations, employers should refer to the provided examples.
How to Register a Car in Louisiana - The application allows for the calculation of taxes, fees, and credits related to the vehicle transaction to ensure correct payment.
Louisiana Trip Permit - The application includes sections for company information, vehicle details, and the specific permit type requested, along with the associated fee.