Form P-142D "Diabetes Medical Report" - Connecticut

What Is Form P-142D?

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-142D 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-142D "Diabetes Medical Report" - Connecticut

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DIABETES MEDICAL REPORT
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
DEPARTMENT OF MOTOR VEHICLES
P-142D REV. 8-2017
DRIVER SERVICES DIVISION
ct.gov/dmv
CDL/PS
YES
NO
Address incident of
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 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 necessary to
X
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)
DATE:
ONSET
HOW LONG HAVE YOU BEEN TREATING THIS
HOW OFTEN DO YOU SEE THIS PATIENT REGARDING
DATE OF LAST EXAMINATION:
PATIENT?
DIABETES?
DIET:
YES
NO
CURRENT
INSULIN:
IF YES, NUMBER OF YEARS/TYPE
DOSAGES:
AM
PM
YES
NO
THERAPY
ORAL AGENT:
IF YES, KIND
DOSAGES:
YES
NO
QUESTIONS:
YES
NO
DOES SYMPTOMATIC HYPOGLYCEMIA OCCUR?
IS GLUCAGON USED OR NEEDED FOR MANAGEMENT?
IS CONSCIOUSNESS LOST OR ALTERED?
IF YES, ON WHAT DATE?
IS THERE A LUCID PRODROME WITH HYPOGLYCEMIA?
DOES PATIENT MANAGE THE EVENT WITHOUT HELP?
ASSOCIATED
DO YOU KNOW IF HYPOGLYCEMIA HAS CONTRIBUTED TO A MOTOR VEHICLE
CLINICAL
IF YES, ON WHAT DATE?
ACCIDENT?
PHENOMENA
IS THERE SIGNIFICANT NEUROPATHY?
SENSORIMOTOR
CRANIAL NERVE
AUTONOMIC
IS THERE SUFFICIENT RETINOPATHY TO ACCOUNT FOR VISION LOSS?
HAS AMPUTATION BEEN NECESSARY?
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S)
WHICH MAY AFFECT HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
DO YOU BELIEVE THIS PATIENT TAKES MEDICATION AS PRESCRIBED?
NOT APPLICABLE
DO YOU HAVE REASON TO SUSPECT THIS PATIENT ABUSES ALCOHOL OR MEDICATIONS
(INCLUDING ILLICIT DRUGS)?
DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT PERIODIC REPORTING?
IF YES, PLEASE INDICATE THE CONDITION(S) AND RECOMMEND MONITORING INTERVAL(S):
YES
NO
CONDITION
EVERY
MONTHS FOR
YEAR(S)
CONDITION
EVERY
MONTHS FOR
YEAR(S)
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY
YES
NO
OPERATE A MOTOR VEHICLE?
ARE THERE ANY CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST?
YES
NO
PLEASE EXPLAIN:
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.
OFFICE ADDRESS (Include Zip Code)
PHYSICIAN'S NAME (Please print or type)
TELEPHONE NUMBER
PHYSICIAN'S LICENSE NUMBER
PHYSICIAN'S SPECIALTY
(
)
PHYSICIAN'S SIGNATURE
DATE REPORT COMPLETED
X
DIABETES MEDICAL REPORT
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
DEPARTMENT OF MOTOR VEHICLES
P-142D REV. 8-2017
DRIVER SERVICES DIVISION
ct.gov/dmv
CDL/PS
YES
NO
Address incident of
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 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 necessary to
X
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)
DATE:
ONSET
HOW LONG HAVE YOU BEEN TREATING THIS
HOW OFTEN DO YOU SEE THIS PATIENT REGARDING
DATE OF LAST EXAMINATION:
PATIENT?
DIABETES?
DIET:
YES
NO
CURRENT
INSULIN:
IF YES, NUMBER OF YEARS/TYPE
DOSAGES:
AM
PM
YES
NO
THERAPY
ORAL AGENT:
IF YES, KIND
DOSAGES:
YES
NO
QUESTIONS:
YES
NO
DOES SYMPTOMATIC HYPOGLYCEMIA OCCUR?
IS GLUCAGON USED OR NEEDED FOR MANAGEMENT?
IS CONSCIOUSNESS LOST OR ALTERED?
IF YES, ON WHAT DATE?
IS THERE A LUCID PRODROME WITH HYPOGLYCEMIA?
DOES PATIENT MANAGE THE EVENT WITHOUT HELP?
ASSOCIATED
DO YOU KNOW IF HYPOGLYCEMIA HAS CONTRIBUTED TO A MOTOR VEHICLE
CLINICAL
IF YES, ON WHAT DATE?
ACCIDENT?
PHENOMENA
IS THERE SIGNIFICANT NEUROPATHY?
SENSORIMOTOR
CRANIAL NERVE
AUTONOMIC
IS THERE SUFFICIENT RETINOPATHY TO ACCOUNT FOR VISION LOSS?
HAS AMPUTATION BEEN NECESSARY?
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S)
WHICH MAY AFFECT HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
DO YOU BELIEVE THIS PATIENT TAKES MEDICATION AS PRESCRIBED?
NOT APPLICABLE
DO YOU HAVE REASON TO SUSPECT THIS PATIENT ABUSES ALCOHOL OR MEDICATIONS
(INCLUDING ILLICIT DRUGS)?
DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT PERIODIC REPORTING?
IF YES, PLEASE INDICATE THE CONDITION(S) AND RECOMMEND MONITORING INTERVAL(S):
YES
NO
CONDITION
EVERY
MONTHS FOR
YEAR(S)
CONDITION
EVERY
MONTHS FOR
YEAR(S)
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY
YES
NO
OPERATE A MOTOR VEHICLE?
ARE THERE ANY CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST?
YES
NO
PLEASE EXPLAIN:
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.
OFFICE ADDRESS (Include Zip Code)
PHYSICIAN'S NAME (Please print or type)
TELEPHONE NUMBER
PHYSICIAN'S LICENSE NUMBER
PHYSICIAN'S SPECIALTY
(
)
PHYSICIAN'S SIGNATURE
DATE REPORT COMPLETED
X