Form 5108E "Medical Condition Report" - Ontario, Canada

What Is Form 5108E?

Form 5108E, Medical Condition Report, is used by health practitioners of Ontario to report patients who are sixteen or over, who are found to have medical or vision difficulties that impact their ability to operate a moving vehicle.

Alternate Name:

  • Ontario Ministry of Transportation (MTO) Medical Form.

This form is issued by the Ontario Ministry of Transportation and was last updated on July 1, 2020. A fillable MTO Medical Form is available for download through the link below.

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MTO Medical Form Instructions

You will need to include the following information to complete the MTO Medical Form:

  1. The full name of the patient, their year of birth, gender, driver's license (if applicable), and current home address.
  2. Your medical office's information, including the name of the person completing the Medical Condition Report, the medical office's address, and your medical professional relationship to the patient (such as a nurse, treating physician, or occupational therapist).
  3. Answers to questions asking about the patient's knowledge that an MTO Medical Form is being completed on their behalf and that you will be releasing the information to the patient or their caregiver if requested.
  4. A detailed list of medical or visual disabilities that can impair the person's driving. All impairments that affect the patient's ability to operate a vehicle will need to be recorded in this section.
    • Cognitive issues such as dementia, a history of strokes, alcohol or drug withdrawal. You will also be asked if these issues are recurring in the patient;
    • Physical impairments such as a spinal cord injury or other impairment that affects muscle strength or control;
    • Visual impairment such as sight perception under 20/50 when examined or severe lack of depth of field in the patient's vision;
    • Severe substance use dependency not including caffeine or nicotine and where the patient has refused to accept a medical practitioner's recommendation for treatment;
    • Psychological impairment where symptoms such as hallucinations, psychoses, or suicidal ideation occur.
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Medical Condition Report
Ministry of Transportation
Fee Code K035
Mandatory report by a prescribed person in compliance with subsection 203 (1) of the Highway Traffic Act,
or Discretionary report in relation to subsection 203 (2) of the Highway Traffic Act. For guidance on
reporting requirements see
Regulation 340/94
or
Interpretive Guide – Form
5108E_Guide.
Complete electronically, print, sign and fax both pages.
Fax Cover
Medical Condition Report Form – 2 Pages
To:
Driver Medical Review 416-235-3400 or 1-800-304-7889
From:
Or Mail to:
Ministry of Transportation - Driver Medical Review
77 Wellesley Street West, Box 589
Toronto ON M7A 1N3
Telephone: 416-235-1773 or 1-800-268-1481
Please complete in full. Fields marked with an asterisk (*) are mandatory.
Part 1. Patient Information
Last Name
*
First Name
*
Middle Init. Date of Birth (yyyy/mm/dd)
*
Gender
*
Driver's Licence Number (if available)
Male
Female
Current Address
Unit Number
Street Number
*
Street Name or Lot
*
PO Box
City/Town/Village
*
Province
*
Postal Code
Part 2. Practitioner's Information
Practitioner's Last Name
*
Practitioner's First Name
*
Practitioner's Address
Unit Number
Street Number
*
Street Name
*
City/Town/Village
*
Province
*
Postal Code
Phone Number
ext.
I am this person's:
Family/Treating Physician
ER Physician
Nurse Practitioner
Occupational Therapist
Urgent Care/Walk In Clinic Physician
Other
Patient is aware of this report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
I approve of the ministry releasing this report to the patient or their legal representative if requested . . . . .
Yes
No
I wish to be notified if my patient requests a copy of this report from the ministry, as releasing this report
Yes
No
may threaten the health or safety of the patient or another individual . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Practitioner's Signature
Date of Report Examination (yyyy/mm/dd)
*
5108E (2020/07)
© Queen's Printer for Ontario, 2020
Disponible en français
Page 1 of 2
Medical Condition Report
Ministry of Transportation
Fee Code K035
Mandatory report by a prescribed person in compliance with subsection 203 (1) of the Highway Traffic Act,
or Discretionary report in relation to subsection 203 (2) of the Highway Traffic Act. For guidance on
reporting requirements see
Regulation 340/94
or
Interpretive Guide – Form
5108E_Guide.
Complete electronically, print, sign and fax both pages.
Fax Cover
Medical Condition Report Form – 2 Pages
To:
Driver Medical Review 416-235-3400 or 1-800-304-7889
From:
Or Mail to:
Ministry of Transportation - Driver Medical Review
77 Wellesley Street West, Box 589
Toronto ON M7A 1N3
Telephone: 416-235-1773 or 1-800-268-1481
Please complete in full. Fields marked with an asterisk (*) are mandatory.
Part 1. Patient Information
Last Name
*
First Name
*
Middle Init. Date of Birth (yyyy/mm/dd)
*
Gender
*
Driver's Licence Number (if available)
Male
Female
Current Address
Unit Number
Street Number
*
Street Name or Lot
*
PO Box
City/Town/Village
*
Province
*
Postal Code
Part 2. Practitioner's Information
Practitioner's Last Name
*
Practitioner's First Name
*
Practitioner's Address
Unit Number
Street Number
*
Street Name
*
City/Town/Village
*
Province
*
Postal Code
Phone Number
ext.
I am this person's:
Family/Treating Physician
ER Physician
Nurse Practitioner
Occupational Therapist
Urgent Care/Walk In Clinic Physician
Other
Patient is aware of this report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Yes
No
I approve of the ministry releasing this report to the patient or their legal representative if requested . . . . .
Yes
No
I wish to be notified if my patient requests a copy of this report from the ministry, as releasing this report
Yes
No
may threaten the health or safety of the patient or another individual . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Practitioner's Signature
Date of Report Examination (yyyy/mm/dd)
*
5108E (2020/07)
© Queen's Printer for Ontario, 2020
Disponible en français
Page 1 of 2
Patient Information
Last Name
First Name
Middle Init. Date of Birth (yyyy/mm/dd)
Part 3. Medical Condition or Impairment – Check all that apply
Cognitive Impairment
A disorder resulting in cognitive impairment that affects attention, judgement and problem solving, planning and sequencing,
memory, insight, reaction time or visuospatial perception, and results in substantial limitation of the person’s ability to perform
activities of daily living. Due to:
Dementia
Brain Injury/Tumour
Unknown
Other (Specify)
Sudden Incapacitation
A disorder that has a moderate or high risk of sudden incapacitation, or that has resulted in sudden incapacitation and that has a
moderate or high risk of recurrence. Due to:
Seizure
Syncope
Alcohol/Drug Withdrawal
Single episode not yet diagnosed
Epilepsy
Recurrent episodes
Stroke
Heart disease with pre-syncope/syncope/arrhythmia
Other (Specify)
CVA resulting in (check all that apply)
Other
Narcolepsy with uncontrolled cataplexy or daytime sleep attacks
Physical Impairment
Obstructive sleep apnea – Untreated or Unsuccessfully Treated with
Cognitive Impairment
Apnea-hypopnea index (AHI) of ≥30 or excessive daytime sleepiness
Visual Field Impairment
Hypoglycaemia requiring intervention of third party or producing LOC
Uncontrolled diabetes or hypoglycaemia
Other (Specify)
Motor or Sensory Impairment
A condition or disorder resulting in severe motor impairment that affects: coordination, muscle strength and control, flexibility,
motor planning, touch or positional sense. Due to:
Neurological Disease (Specify)
Spinal Cord Injury
Loss of Limb
Other (Specify)
Visual Impairment
Best corrected visual acuity below 20/50 with both eyes open and examined together
Visual field less than 120 continuous degrees along the horizontal meridian, or less than 15 continuous degrees above
and below fixation, or less than 60 degrees to either side of the vertical meridian, including hemianopia.
Diplopia within 40 degrees of fixation point (in all directions) of primary position, that cannot be corrected using prism lenses
or patching.
Substance Use Disorder
A diagnosis of an uncontrolled substance use disorder, excluding caffeine and nicotine, and patient is non-compliant with
treatment recommendations.
Alcohol
Other Substances (Specify)
Psychiatric Illness
A condition or disorder currently involving any of the following: acute psychosis, severe abnormalities of perception, or patient
has a suicidal plan involving a vehicle or an intent to use a vehicle to harm others.
Due to:
Part 4. Discretionary report of Medical Condition or Impairment
Please describe condition(s) or impairment
5108E (2020/07)
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