Form MAB106 "Medical Evaluation Form" - Massachusetts

What Is Form MAB106?

This is a legal form that was released by the Massachusetts Registry of Motor Vehicles - a government authority operating within Massachusetts. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2018;
  • The latest edition provided by the Massachusetts Registry 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 MAB106 by clicking the link below or browse more documents and templates provided by the Massachusetts Registry of Motor Vehicles.

ADVERTISEMENT
ADVERTISEMENT

Download Form MAB106 "Medical Evaluation Form" - Massachusetts

997 times
Rate (4.6 / 5) 50 votes
Medical Evaluation Form
Medical Affairs ● P.O. Box 55889, Boston, MA 02205-5889
Fax: 857-368-0018
I hereby authorize the physician completing this form to discuss and release any or all medical records pertaining to its
content with or to representatives of the Registry of Motor Vehicles.
Applicant’s Signature: ___________________________________________________ Date: ___________________
This form must be fully completed by a physician: a medical doctor who is licensed to practice in the
Commonwealth of Massachusetts.
A. Patient Information
Last Name
First Name
Middle Name
Suffix
Driver’s License #
Date of Birth (MM/DD/YYYY)
Reported Condition
The Registry of Motor Vehicles has received information that the patient named above may have a condition which could
affect the patient’s ability to operate a motor vehicle. Please complete the following:
1. Please describe the patient's medical condition: _________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
A. Does the patient have a respiratory disease/disorder? ........................................................................  Yes  No
If so, indicate the patient’s O² saturation rate at rest or with minimal exertion (with supplemental O², if used)
____________________________________________________________________________________________
____________________________________________________________________________________________
Other comments: _____________________________________________________________________________
____________________________________________________________________________________________
B. Does the patient have a cardiovascular condition? ..............................................................................  Yes  No
1) Does the patient have an implanted cardiac defibrillator? .......................................................  Yes  No
If so,
2) Specify the American Heart Association (“AHA”) functional class which most appropriately
describes the patient’s condition (see guidelines on reverse side) and symptoms
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
2. Please describe the extent, frequency, and control of the symptoms of the patient’s condition or disability which may
affect the patient’s ability to operate a motor vehicle:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3. Is the patient's medical condition or disability likely to interfere with the patient’s mental
or physical ability to operate a motor vehicle safely? ...................................................................................  Yes  No
If yes, describe:
p.1
MAB106_1018
Medical Evaluation Form
Medical Affairs ● P.O. Box 55889, Boston, MA 02205-5889
Fax: 857-368-0018
I hereby authorize the physician completing this form to discuss and release any or all medical records pertaining to its
content with or to representatives of the Registry of Motor Vehicles.
Applicant’s Signature: ___________________________________________________ Date: ___________________
This form must be fully completed by a physician: a medical doctor who is licensed to practice in the
Commonwealth of Massachusetts.
A. Patient Information
Last Name
First Name
Middle Name
Suffix
Driver’s License #
Date of Birth (MM/DD/YYYY)
Reported Condition
The Registry of Motor Vehicles has received information that the patient named above may have a condition which could
affect the patient’s ability to operate a motor vehicle. Please complete the following:
1. Please describe the patient's medical condition: _________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
A. Does the patient have a respiratory disease/disorder? ........................................................................  Yes  No
If so, indicate the patient’s O² saturation rate at rest or with minimal exertion (with supplemental O², if used)
____________________________________________________________________________________________
____________________________________________________________________________________________
Other comments: _____________________________________________________________________________
____________________________________________________________________________________________
B. Does the patient have a cardiovascular condition? ..............................................................................  Yes  No
1) Does the patient have an implanted cardiac defibrillator? .......................................................  Yes  No
If so,
2) Specify the American Heart Association (“AHA”) functional class which most appropriately
describes the patient’s condition (see guidelines on reverse side) and symptoms
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
2. Please describe the extent, frequency, and control of the symptoms of the patient’s condition or disability which may
affect the patient’s ability to operate a motor vehicle:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3. Is the patient's medical condition or disability likely to interfere with the patient’s mental
or physical ability to operate a motor vehicle safely? ...................................................................................  Yes  No
If yes, describe:
p.1
MAB106_1018
Patient Name: _______________________________________
Last 4 Social: __________
4. If condition involves seizure or any type of altered or loss of consciousness, please state type and date of last
episode(s).
________________________________________________________________________________________________________
________________________________________________________________________________________________________
5. Is patient on any medication(s)? ..................................................................................................................  Yes  No
If yes, list medication(s) with dosage(s): _______________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
Are these medications, separately or in combination, likely to interfere with the patient’s ability to operate a motor
vehicle safely? ..............................................................................................................................................  Yes  No
6. Please check one of the following categories:
I hereby certify that in my professional opinion and to a reasonable degree of medical certainty, one of the following:
 The patient named above is medically qualified to operate a motor vehicle safely.
 The patient named above is NOT medically qualified to operate a motor vehicle safely.
 The patient may require adaptive equipment and/or an assessment for appropriate license restrictions via a
competency road examination.
 I am unable to determine driving ability and recommend the patient undergo a competency road examination.
7. Please check one:
I have read the attached police report and am aware of the reported incident involving
my patient. .....................................................................................................................................  Yes  No  N/A
Additional comments: ______________________________________________________________________________
________________________________________________________________________________________________________
B. Physician Certification
Physician’s Name
National Provider Number (NPI #)
Massachusetts Board of Registration #
Address
Zip
-
Street
City
State
Code
I hereby certify, under the pains and penalties of perjury, that the information I have provided herein is true,
accurate and complete.
Certifying Physician’s Signature: __________________________________________ Date: ___________________
Classification Guidelines:
AM E R I C A N A S S O C I AT I O N F U N C T I O N AL C L A S S I F I C A T I O N S Y S T E M
CLASS I
Patients with cardiac disease but without resulting limitations of physical activity. Ordinary physical activity does not
cause fatigue, palpitation, dyspnea, or anginal pain.
CLASS II
Patients with cardiac disease resulting in slight limitation of physical activity. They are comfortable at rest. Ordinary
physical activity result in fatigue, palpitation, dyspnea, or anginal pain.
CLASS III
Patients with cardiac disease resulting in marked limitation of physical activity. They are comfortable at rest. Less
than ordinary physical activity causes fatigue, palpitation, dyspnea, or anginal pain.
CLASS IV
Patients with cardiac disease resulting in inability to carry on any physical activity without discomfort. Symptoms of
cardiac insufficiency or of the anginal syndrome may be present even at rest. If any physical activity is undertaken,
discomfort is increased
p.2
MAB106_1018
Page of 2