Form P-142C "Cardiology Medical Report" - Connecticut

What Is Form P-142C?

This is a legal form that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2017;
  • The latest edition provided by the Connecticut Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form P-142C by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form P-142C "Cardiology Medical Report" - Connecticut

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STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
CARDIOLOGY MEDICAL REPORT
DEPARTMENT OF MOTOR VEHICLES
P-142C REV. 8-2017
DRIVER SERVICES DIVISION
ct.gov/dmv
CDL/PS
YES
NO
MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
The patient named below has been referred to the DMV Driver Services Division concerning their ability to
Address incident of
operate a motor vehicle safely. This medical report must reflect the results of the licensed physician's personal
examination of the patient performed within 90 days of this report being filed. It must be signed by the patient
authorizing the physician to release this report and any attachments to DMV.
PATIENT'S SIGNATURE
DATE
I hereby authorize the licensed physician completing and signing this medical
report to release such report to DMV along with any other medical information
X
necessary to determine my fitness to operate a motor vehicle safely.
PATIENT'S NAME (Please Print)
(Last)
(First)
(Initial)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
PATIENT'S ADDRESS (Street)
(City)
(State)
(Zip Code)
HOW LONG HAVE YOU BEEN TREATING THIS PATIENT?
DATE OF LAST EXAMINATION
CONDITION(S) RELEVANT TO SAFE OPERATION OF A MOTOR VEHICLE
TECHNICAL REPORT(S) (e.g., ECHO, SCAN, HOLTER, EKG, CATH) WITH FINDINGS RELEVANT TO OPERATING A MOTOR VEHICLE SAFELY:
DATE
TEST
RESULT
1.
2.
3.
TYPE
DATE
LAST EPISODE OF ALTERED CIRCULATORY STABILITY SUFFICIENT
TO INTERFERE WITH OPERATING A MOTOR VEHICLE SAFELY.
MEDICATIONS (RELEVANT TO MOTOR VEHICLE OPERATION)
NAME OF MEDICATION
DOSE
NAME OF MEDICATION
DOSE
NAME OF MEDICATION
DOSE
ABNORMALITIES ON CARDIAC EXAMINATION:
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S)
YES
NO
WHICH MAY AFFECT HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
YES
NO
NOT APPLICABLE
DO YOU BELIEVE THIS PATIENT TAKES MEDICATION AS PRESCRIBED?
YES
NO
DO YOU HAVE REASON TO SUSPECT THIS PATIENT ABUSES ALCOHOL OR MEDICATIONS (INCLUDING ILLICIT DRUGS)?
YES
NO
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR VEHICLE?
DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT PERIODIC REPORTING?
YES
NO
IF YES, PLEASE INDICATE THE CONDITION(S) AND RECOMMEND MONITORING INTERVAL(S):
CONDITION
EVERY
MONTHS FOR
YEAR(S)
CONDITION
EVERY
MONTHS FOR
YEAR(S)
ARE THERE ANY CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST? PLEASE EXPLAIN:
ADDITIONAL COMMENT(S):
PHYSICIAN'S CERTIFICATION: I certify that I have personally examined the above named person within the 90 days preceding completion of this report. I swear or affirm under
penalty of false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, and subject to penalties for perjury for a deliberate false statement, that the
above information and any attachment hereto is true and correct.
PHYSICIAN'S NAME (Please print or type)
OFFICE ADDRESS (Include Zip Code)
TELEPHONE NUMBER
PHYSICIAN'S LICENSE NUMBER
PHYSICIAN'S SPECIALTY
(
)
PHYSICIAN'S SIGNATURE
DATE REPORT COMPLETED
X
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
CARDIOLOGY MEDICAL REPORT
DEPARTMENT OF MOTOR VEHICLES
P-142C REV. 8-2017
DRIVER SERVICES DIVISION
ct.gov/dmv
CDL/PS
YES
NO
MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
The patient named below has been referred to the DMV Driver Services Division concerning their ability to
Address incident of
operate a motor vehicle safely. This medical report must reflect the results of the licensed physician's personal
examination of the patient performed within 90 days of this report being filed. It must be signed by the patient
authorizing the physician to release this report and any attachments to DMV.
PATIENT'S SIGNATURE
DATE
I hereby authorize the licensed physician completing and signing this medical
report to release such report to DMV along with any other medical information
X
necessary to determine my fitness to operate a motor vehicle safely.
PATIENT'S NAME (Please Print)
(Last)
(First)
(Initial)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
PATIENT'S ADDRESS (Street)
(City)
(State)
(Zip Code)
HOW LONG HAVE YOU BEEN TREATING THIS PATIENT?
DATE OF LAST EXAMINATION
CONDITION(S) RELEVANT TO SAFE OPERATION OF A MOTOR VEHICLE
TECHNICAL REPORT(S) (e.g., ECHO, SCAN, HOLTER, EKG, CATH) WITH FINDINGS RELEVANT TO OPERATING A MOTOR VEHICLE SAFELY:
DATE
TEST
RESULT
1.
2.
3.
TYPE
DATE
LAST EPISODE OF ALTERED CIRCULATORY STABILITY SUFFICIENT
TO INTERFERE WITH OPERATING A MOTOR VEHICLE SAFELY.
MEDICATIONS (RELEVANT TO MOTOR VEHICLE OPERATION)
NAME OF MEDICATION
DOSE
NAME OF MEDICATION
DOSE
NAME OF MEDICATION
DOSE
ABNORMALITIES ON CARDIAC EXAMINATION:
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S)
YES
NO
WHICH MAY AFFECT HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
YES
NO
NOT APPLICABLE
DO YOU BELIEVE THIS PATIENT TAKES MEDICATION AS PRESCRIBED?
YES
NO
DO YOU HAVE REASON TO SUSPECT THIS PATIENT ABUSES ALCOHOL OR MEDICATIONS (INCLUDING ILLICIT DRUGS)?
YES
NO
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR VEHICLE?
DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT PERIODIC REPORTING?
YES
NO
IF YES, PLEASE INDICATE THE CONDITION(S) AND RECOMMEND MONITORING INTERVAL(S):
CONDITION
EVERY
MONTHS FOR
YEAR(S)
CONDITION
EVERY
MONTHS FOR
YEAR(S)
ARE THERE ANY CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST? PLEASE EXPLAIN:
ADDITIONAL COMMENT(S):
PHYSICIAN'S CERTIFICATION: I certify that I have personally examined the above named person within the 90 days preceding completion of this report. I swear or affirm under
penalty of false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, and subject to penalties for perjury for a deliberate false statement, that the
above information and any attachment hereto is true and correct.
PHYSICIAN'S NAME (Please print or type)
OFFICE ADDRESS (Include Zip Code)
TELEPHONE NUMBER
PHYSICIAN'S LICENSE NUMBER
PHYSICIAN'S SPECIALTY
(
)
PHYSICIAN'S SIGNATURE
DATE REPORT COMPLETED
X