Form P-142M "Medical Form" - Connecticut

What Is Form P-142M?

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 July 1, 2018;
  • 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-142M 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-142M "Medical Form" - Connecticut

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MEDICAL FORM
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
P-142M Rev. 7-18
60 STATE STREET, WETHERSFIELD, CT 06161-1013
DRIVER SERVICES DIVISION
ct.gov/dmv
Department of Rehabilitation Services/
Driver Training Program Referral
This patient has been referred to the DMV concerning his or her ability to safely operate a motor vehicle.
INSTRUCTIONS
Patient: Complete section (A).
Medical examiner(s) (licensed physician, PA or APRN): Complete section (B) and any applicable subsection of section (C) based on the results of a personal examination
conducted within 90 days of the completion of this report. Attach other information as necessary, including any technical reports or test results.
Submission of this report to the DMV is authorized pursuant to Section 14-46 of the Connecticut General Statutes and no civil action may be brought against any person who, in
good faith, provides a report. Based upon all available information, DMV will make a final decision concerning the patient's ability to hold an operator's license.
Section (A): Patient Information
OPERATOR'S LICENSE NUMBER
NAME (Last, First, Middle)
DATE OF BIRTH
PATIENT PHONE NUMBER
MAILING ADDRESS
(City)
(State)
(Zip Code)
(Street)
I hereby authorize and accept that my medical examiner will conduct a medical examination to determine my fitness to operate a motor vehicle safely and
may submit copies of my medical records to the DMV and/or the Department of Rehabilitation Services.
DATE
SIGNATURE OF DRIVER/PATIENT
X
BELOW TO BE COMPLETED BY MEDICAL EXAMINER.
Section (B): Clinical Information and Safety Implications
EXAMINATION DATE
Use space below
ADDRESS INCIDENT OF
Are you a regular or primary
YES
NO
care provider for this patient?
PLEASE INDICATE BELOW ANY PRESENT CONDITIONS THAT MAY AFFECT THIS PATIENT'S ABILITY TO DRIVE SAFELY AND/OR ADDRESS
INCIDENT DATE NOTED ABOVE.
The person named above is NOT medically qualified to operate a motor vehicle.
YES
NO
Do you believe this person should be required to complete a DMV road test to determine driving ability?
DMV may require periodic reporting to ensure there has been no change in a patient's ability to drive safely. Considering this patient's condition,
should periodic reports be submitted to DMV?
YES
NO
If yes, for which condition(s) should the patient provide a report:
How often should a report be filed?
Every
months for
year(s).
Is this patient's movement limited?
YES
NO
YES
NO
If yes, what equipment?
Does this patient's condition require that he or she operate a vehicle with special equipment?
Should this patient be limited to operating a motor vehicle with any of the following restrictions?
MECHANICAL AID (C)
PROSTHETIC AID (D)
AUTOMATIC TRANSMISSION (E)
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate false statement in
accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and correct.
MEDICAL EXAMINER'S NAME
LICENSE NUMBER
MEDICAL EXAMINER'S SIGNATURE
SPECIALTY
X
TELEPHONE NUMBER
DATE
Section (C): Condition-Specific Information (Continued on Page 2)
CARDIOLOGY
Patient has no known cardiac condition
Abnormalities on cardiac examination:
Has patient suffered lost or altered consciousness?
YES
NO
If yes, on what date(s)?
List any known medication, which may produce side-effects, that may impact a patient's ability to safely operate a motor vehicle. Include dosage:
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate false statement in
accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and correct.
MEDICAL EXAMINER'S NAME
MEDICAL EXAMINER'S SIGNATURE
LICENSE NUMBER
SPECIALTY
X
TELEPHONE NUMBER
DATE
Page 1 of 2
MEDICAL FORM
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
P-142M Rev. 7-18
60 STATE STREET, WETHERSFIELD, CT 06161-1013
DRIVER SERVICES DIVISION
ct.gov/dmv
Department of Rehabilitation Services/
Driver Training Program Referral
This patient has been referred to the DMV concerning his or her ability to safely operate a motor vehicle.
INSTRUCTIONS
Patient: Complete section (A).
Medical examiner(s) (licensed physician, PA or APRN): Complete section (B) and any applicable subsection of section (C) based on the results of a personal examination
conducted within 90 days of the completion of this report. Attach other information as necessary, including any technical reports or test results.
Submission of this report to the DMV is authorized pursuant to Section 14-46 of the Connecticut General Statutes and no civil action may be brought against any person who, in
good faith, provides a report. Based upon all available information, DMV will make a final decision concerning the patient's ability to hold an operator's license.
Section (A): Patient Information
OPERATOR'S LICENSE NUMBER
NAME (Last, First, Middle)
DATE OF BIRTH
PATIENT PHONE NUMBER
MAILING ADDRESS
(City)
(State)
(Zip Code)
(Street)
I hereby authorize and accept that my medical examiner will conduct a medical examination to determine my fitness to operate a motor vehicle safely and
may submit copies of my medical records to the DMV and/or the Department of Rehabilitation Services.
DATE
SIGNATURE OF DRIVER/PATIENT
X
BELOW TO BE COMPLETED BY MEDICAL EXAMINER.
Section (B): Clinical Information and Safety Implications
EXAMINATION DATE
Use space below
ADDRESS INCIDENT OF
Are you a regular or primary
YES
NO
care provider for this patient?
PLEASE INDICATE BELOW ANY PRESENT CONDITIONS THAT MAY AFFECT THIS PATIENT'S ABILITY TO DRIVE SAFELY AND/OR ADDRESS
INCIDENT DATE NOTED ABOVE.
The person named above is NOT medically qualified to operate a motor vehicle.
YES
NO
Do you believe this person should be required to complete a DMV road test to determine driving ability?
DMV may require periodic reporting to ensure there has been no change in a patient's ability to drive safely. Considering this patient's condition,
should periodic reports be submitted to DMV?
YES
NO
If yes, for which condition(s) should the patient provide a report:
How often should a report be filed?
Every
months for
year(s).
Is this patient's movement limited?
YES
NO
YES
NO
If yes, what equipment?
Does this patient's condition require that he or she operate a vehicle with special equipment?
Should this patient be limited to operating a motor vehicle with any of the following restrictions?
MECHANICAL AID (C)
PROSTHETIC AID (D)
AUTOMATIC TRANSMISSION (E)
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate false statement in
accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and correct.
MEDICAL EXAMINER'S NAME
LICENSE NUMBER
MEDICAL EXAMINER'S SIGNATURE
SPECIALTY
X
TELEPHONE NUMBER
DATE
Section (C): Condition-Specific Information (Continued on Page 2)
CARDIOLOGY
Patient has no known cardiac condition
Abnormalities on cardiac examination:
Has patient suffered lost or altered consciousness?
YES
NO
If yes, on what date(s)?
List any known medication, which may produce side-effects, that may impact a patient's ability to safely operate a motor vehicle. Include dosage:
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate false statement in
accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and correct.
MEDICAL EXAMINER'S NAME
MEDICAL EXAMINER'S SIGNATURE
LICENSE NUMBER
SPECIALTY
X
TELEPHONE NUMBER
DATE
Page 1 of 2
LICENSE NUMBER:
DIABETES/METABOLIC
Patient has no known diabetic/metabolic condition
Is patient on insulin treatment?
Does this patient suffer from severe hypoglycemia?
YES
NO
YES
NO
YES
NO
Has patient suffered lost or altered consciousness?
If yes, on what date(s)?
If yes, does it affect motor vehicle operation?
Is there significant neuropathy?
YES
NO
YES
NO
Has patient suffered retinopathy to the point of vision loss?
YES
NO
List any known medication, which may produce side-effects, that may impact a patient's ability to safely operate a motor vehicle. Include dosage:
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate false statement in
accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and correct.
MEDICAL EXAMINER'S NAME
MEDICAL EXAMINER'S SIGNATURE
LICENSE NUMBER
SPECIALTY
X
TELEPHONE NUMBER
DATE
NEUROLOGY
Patient has no known neurological condition
Name(s) of specific neurological condition(s) present:
State episodes of lost or altered consciousness or awareness within the past two years:
Cause:
Date:
Cause:
Date:
Cause:
Date:
Provide the following medication information relevant to safe operation of a motor vehicle:
BLOOD LEVEL
DATE OF LAB WORK
TYPE/DOSE
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate false statement in
accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and correct.
MEDICAL EXAMINER'S NAME
MEDICAL EXAMINER'S SIGNATURE
LICENSE NUMBER
SPECIALTY
X
TELEPHONE NUMBER
DATE
PSYCHIATRIC/SUBSTANCE ABUSE
Patient has no known psychiatric/substance abuse condition
Name(s) of specific psychiatric condition(s) present:
YES
NO
Do you have reason to suspect the patient abuses alcohol, illicit drugs or medication?
If yes, please explain:
Date of last episode:
Does this patient suffer from convulsive seizures?
YES
NO
List any known medication, which may produce side-effects, that may impact a patient's ability to safely operate a motor vehicle. Include dosage:
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate false statement in
accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and correct.
MEDICAL EXAMINER'S NAME
MEDICAL EXAMINER'S SIGNATURE
LICENSE NUMBER
SPECIALTY
X
TELEPHONE NUMBER
DATE
RESPIRATORY/SLEEP DISORDERS
Patient has no known respiratory/sleep disorder condition
Name(s) of specific respiratory/sleep disorder condition(s) present:
Does the patient require use of a CPAP machine?
Is the patient compliant with the use of
YES
NO
YES
NO
the CPAP machine?
Is this patient able to exhale 1000CC of air in one continuous breath during the operation of an ignition interlock device?
YES
NO
List any known medication, which may produce side-effects, that may impact a patient's ability to safely operate a motor vehicle. Include dosage:
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate false statement in
accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and correct.
MEDICAL EXAMINER'S NAME
MEDICAL EXAMINER'S SIGNATURE
LICENSE NUMBER
SPECIALTY
X
TELEPHONE NUMBER
DATE
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