Form P-142OR "Orthopedic Medical Report" - Connecticut

What Is Form P-142OR?

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-142OR 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-142OR "Orthopedic Medical Report" - Connecticut

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ORTHOPEDIC MEDICAL REPORT
DRIVER'S LICENSE NUMBER
STATE OF CONNECTICUT
P-142OR REV. 8-2017
DEPARTMENT OF MOTOR VEHICLES
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)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
(City)
(State)
(Zip Code)
PATIENT'S ADDRESS
(Street)
DATE OF LAST EXAMINATION
IF YES, COMMENT AS TO PROGRESS
IS THIS A PROGRESSIVE ILLNESS?
YES
NO
IF YES, SPECIFY
ARE THERE SPLINTS OR APPLIANCES THAT SHOULD BE WORN
YES
NO
WHILE PATIENT IS OPERATING A MOTOR VEHICLE?
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED
DO YOU BELIEVE THIS PATIENT TAKES MEDICATIONS
BY HIS/HER CONDITION(S) WHICH MAY AFFECT HIS/HER ABILITY
YES
NO
YES
NO
AS PRESCRIBED?
TO SAFELY OPERATE A MOTOR VEHICLE?
ABNORMALITIES ON ORTHOPEDIC EXAMINATION
ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST?
PLEASE EXPLAIN
NO
YES
YES
NO
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR VEHICLE?
IN YOUR OPINION, SHOULD THE DMV PERMIT THIS INDIVIDUAL TO HOLD AN UNRESTRICTED OPERATOR'S LICENSE?
YES
NO
IF NO, WOULD THIS INDIVIDUAL BE SAFE TO OPERATE A MOTOR VEHICLE WITH CERTAIN RESTRICTIONS?
YES
NO
PLEASE CHECK APPROPRIATE RESTRICTION:
MECHANICAL AID (C)
AUTOMATIC TRANSMISSION (E)
PROSTHETIC AID (D)
NO LIMITED ACCESS ROADS (R)
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
ORTHOPEDIC MEDICAL REPORT
DRIVER'S LICENSE NUMBER
STATE OF CONNECTICUT
P-142OR REV. 8-2017
DEPARTMENT OF MOTOR VEHICLES
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)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
(City)
(State)
(Zip Code)
PATIENT'S ADDRESS
(Street)
DATE OF LAST EXAMINATION
IF YES, COMMENT AS TO PROGRESS
IS THIS A PROGRESSIVE ILLNESS?
YES
NO
IF YES, SPECIFY
ARE THERE SPLINTS OR APPLIANCES THAT SHOULD BE WORN
YES
NO
WHILE PATIENT IS OPERATING A MOTOR VEHICLE?
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED
DO YOU BELIEVE THIS PATIENT TAKES MEDICATIONS
BY HIS/HER CONDITION(S) WHICH MAY AFFECT HIS/HER ABILITY
YES
NO
YES
NO
AS PRESCRIBED?
TO SAFELY OPERATE A MOTOR VEHICLE?
ABNORMALITIES ON ORTHOPEDIC EXAMINATION
ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST?
PLEASE EXPLAIN
NO
YES
YES
NO
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR VEHICLE?
IN YOUR OPINION, SHOULD THE DMV PERMIT THIS INDIVIDUAL TO HOLD AN UNRESTRICTED OPERATOR'S LICENSE?
YES
NO
IF NO, WOULD THIS INDIVIDUAL BE SAFE TO OPERATE A MOTOR VEHICLE WITH CERTAIN RESTRICTIONS?
YES
NO
PLEASE CHECK APPROPRIATE RESTRICTION:
MECHANICAL AID (C)
AUTOMATIC TRANSMISSION (E)
PROSTHETIC AID (D)
NO LIMITED ACCESS ROADS (R)
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