Form P-142N "Neurology Medical Report" - Connecticut

What Is Form P-142N?

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-142N 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-142N "Neurology Medical Report" - Connecticut

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DRIVER'S LICENSE NUMBER
NEUROLOGY MEDICAL REPORT
STATE OF CONNECTICUT
P-142N REV. 8-17
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
CDL/PS
YES
NO
ct.gov/dmv
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.
I hereby authorize the licensed physician completing and signing this medical report to
PATIENT'S SIGNATURE
DATE
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
(
)
(Street)
(City)
(Zip Code)
PATIENT'S ADDRESS
(State)
HOW LONG HAVE YOU BEEN TREATING THIS PATIENT?
DATE OF LAST EXAMINATION
HOW MANY YEARS HAS THIS PATIENT HAD THE CONDITION(S) YOU ARE TREATING? PLEASE PROVIDE A BRIEF DIAGNOSIS, ETIOLOGY, AND PROGNOSIS,
INCLUDING DATES AND RESULTS OF EEG SCANS, AND/OR OTHER TEST RESULTS, AS NEEDED.
ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST? PLEASE EXPLAIN:
HISTORY OF EPISODES OF ALTERED CONSCIOUSNESS IN THE PAST TWO YEARS
DATE
TYPE
DATE
TYPE
DATE
TYPE
1.
3.
5.
2.
4.
6.
MEDICATIONS (RELEVANT TO MOTOR VEHICLE OPERATION)
DATE OF LAB WORK
TYPE/DOSE
BLOOD LEVEL
DATE OF LAB WORK
TYPE/DOSE
BLOOD LEVEL
1.
3.
2.
4.
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):
NO
YES
CONDITION
EVERY
MONTHS FOR
YEAR(S)
EVERY
MONTHS FOR
YEAR(S)
CONDITION
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S)
NO
YES
WHICH MAY AFFECT HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
DO YOU BELIEVE THIS PATIENT TAKES MEDICATION AS PRESCRIBED?
YES
NO
NOT APPLICABLE
DO YOU HAVE REASON TO SUSPECT THIS PATIENT ABUSES ALCOHOL OR MEDICATIONS
YES
NO
(INCLUDING ILLICIT DRUGS)?
ARE YOU AWARE OF ANY OTHER RELEVANT MEDICAL OR SURGICAL HISTORY? PLEASE EXPLAIN:
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A
YES
NO
MOTOR VEHICLE?
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)
PHYSICIAN'S LICENSE NUMBER
PHYSICIAN'S SPECIALTY
TELEPHONE NUMBER
(
)
PHYSICIAN'S SIGNATURE
DATE REPORT COMPLETED
X
DRIVER'S LICENSE NUMBER
NEUROLOGY MEDICAL REPORT
STATE OF CONNECTICUT
P-142N REV. 8-17
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
CDL/PS
YES
NO
ct.gov/dmv
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.
I hereby authorize the licensed physician completing and signing this medical report to
PATIENT'S SIGNATURE
DATE
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
(
)
(Street)
(City)
(Zip Code)
PATIENT'S ADDRESS
(State)
HOW LONG HAVE YOU BEEN TREATING THIS PATIENT?
DATE OF LAST EXAMINATION
HOW MANY YEARS HAS THIS PATIENT HAD THE CONDITION(S) YOU ARE TREATING? PLEASE PROVIDE A BRIEF DIAGNOSIS, ETIOLOGY, AND PROGNOSIS,
INCLUDING DATES AND RESULTS OF EEG SCANS, AND/OR OTHER TEST RESULTS, AS NEEDED.
ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST? PLEASE EXPLAIN:
HISTORY OF EPISODES OF ALTERED CONSCIOUSNESS IN THE PAST TWO YEARS
DATE
TYPE
DATE
TYPE
DATE
TYPE
1.
3.
5.
2.
4.
6.
MEDICATIONS (RELEVANT TO MOTOR VEHICLE OPERATION)
DATE OF LAB WORK
TYPE/DOSE
BLOOD LEVEL
DATE OF LAB WORK
TYPE/DOSE
BLOOD LEVEL
1.
3.
2.
4.
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):
NO
YES
CONDITION
EVERY
MONTHS FOR
YEAR(S)
EVERY
MONTHS FOR
YEAR(S)
CONDITION
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S)
NO
YES
WHICH MAY AFFECT HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
DO YOU BELIEVE THIS PATIENT TAKES MEDICATION AS PRESCRIBED?
YES
NO
NOT APPLICABLE
DO YOU HAVE REASON TO SUSPECT THIS PATIENT ABUSES ALCOHOL OR MEDICATIONS
YES
NO
(INCLUDING ILLICIT DRUGS)?
ARE YOU AWARE OF ANY OTHER RELEVANT MEDICAL OR SURGICAL HISTORY? PLEASE EXPLAIN:
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A
YES
NO
MOTOR VEHICLE?
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)
PHYSICIAN'S LICENSE NUMBER
PHYSICIAN'S SPECIALTY
TELEPHONE NUMBER
(
)
PHYSICIAN'S SIGNATURE
DATE REPORT COMPLETED
X