Form P-142P/S "Psychiatric/Substance Abuse Medical Report" - Connecticut

What Is Form P-142P/S?

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-142P/S by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

ADVERTISEMENT
ADVERTISEMENT

Download Form P-142P/S "Psychiatric/Substance Abuse Medical Report" - Connecticut

985 times
Rate (4.6 / 5) 59 votes
PSYCHIATRIC/SUBSTANCE ABUSE
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
DEPARTMENT OF MOTOR VEHICLES
MEDICAL REPORT
DRIVER SERVICES DIVISION
P-142P/S REV. 8-2017
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 necessary to
X
determine my fitness to operate a motor vehicle safely.
PATIENT'S NAME (Please Print)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
(Street)
(City)
(State)
(Zip Code)
PATIENT'S ADDRESS
DATE OF LAST EXAMINATION
CATEGORY OF MEDICATIONS
ANTIDEPRESSANTS
ANXIOLYTICS
MOOD STABILIZERS
METHADONE
NEUROLYTICS
SEDATIVES
ANTABUSE
NALTREXAN (Trexan)
MEDICATIONS (RELEVANT TO MOTOR VEHICLE OPERATION)
NAME OF MEDICATION
DOSE
NAME OF MEDICATION
DOSE
NAME OF MEDICATION
DOSE
MONTH
YEAR
TYPE
DOES PATIENT CURRENTLY SUFFER FROM
DATE OF
YES
NO
CONVULSIVE SEIZURES?
LAST EPISODE
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S) WHICH MAY AFFECT HIS/HER
YES
NO
ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
YES
NO
DO YOU BELIEVE THIS PERSON TAKES MEDICATIONS AS PRESCRIBED?
IF YES, (Please elaborate)
DO YOU HAVE REASON TO SUSPECT THE PATIENT ABUSES ALCOHOL, MEDICATIONS, OR ILLICIT DRUGS?
YES
NO
DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT
PERIODIC MEDICAL 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)
ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST?
(Please Explain)
YES
NO
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR
(Please Explain)
YES
NO
VEHICLE?
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON SHOULD BE ROAD TESTED AND/OR
YES
NO
EVALUATED FOR SPECIAL EQUIPMENT REQUIREMENTS?
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
PSYCHIATRIC/SUBSTANCE ABUSE
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
DEPARTMENT OF MOTOR VEHICLES
MEDICAL REPORT
DRIVER SERVICES DIVISION
P-142P/S REV. 8-2017
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 necessary to
X
determine my fitness to operate a motor vehicle safely.
PATIENT'S NAME (Please Print)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
(Street)
(City)
(State)
(Zip Code)
PATIENT'S ADDRESS
DATE OF LAST EXAMINATION
CATEGORY OF MEDICATIONS
ANTIDEPRESSANTS
ANXIOLYTICS
MOOD STABILIZERS
METHADONE
NEUROLYTICS
SEDATIVES
ANTABUSE
NALTREXAN (Trexan)
MEDICATIONS (RELEVANT TO MOTOR VEHICLE OPERATION)
NAME OF MEDICATION
DOSE
NAME OF MEDICATION
DOSE
NAME OF MEDICATION
DOSE
MONTH
YEAR
TYPE
DOES PATIENT CURRENTLY SUFFER FROM
DATE OF
YES
NO
CONVULSIVE SEIZURES?
LAST EPISODE
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK POSED BY HIS/HER CONDITION(S) WHICH MAY AFFECT HIS/HER
YES
NO
ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
YES
NO
DO YOU BELIEVE THIS PERSON TAKES MEDICATIONS AS PRESCRIBED?
IF YES, (Please elaborate)
DO YOU HAVE REASON TO SUSPECT THE PATIENT ABUSES ALCOHOL, MEDICATIONS, OR ILLICIT DRUGS?
YES
NO
DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT
PERIODIC MEDICAL 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)
ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST?
(Please Explain)
YES
NO
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR
(Please Explain)
YES
NO
VEHICLE?
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON SHOULD BE ROAD TESTED AND/OR
YES
NO
EVALUATED FOR SPECIAL EQUIPMENT REQUIREMENTS?
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