Form DA-4P "Physician's Statement of Examination" - Michigan

What Is Form DA-4P?

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

Form Details:

  • Released on March 16, 2021;
  • The latest edition provided by the Michigan Department of State;
  • 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 DA-4P by clicking the link below or browse more documents and templates provided by the Michigan Department of State.

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PHYSICIAN’S STATEMENT OF EXAMINATION
Michigan Department of State
P.O. Box 30810, Lansing, Michigan 48909-9832
Phone: 517-335-7051; Fax: 517-335-2189; email: MedicalForms@Michigan.gov
Michigan.gov/SOS
Reason for Referral
(to be completed by Department of State personnel or referring health care provider)
Reason for Referral:
Driver indicated a loss or impairment of consciousness within last:
6 months
12 months or more
Date:
Driver may have a medical condition that could affect safe driving within the last:
6 months
12 months or more
Name and Title of Referrer:
Signature of Referrer:
Telephone
Instructions for Driver/Applicant
1. Complete Sections 1 through 4 with all of the information that applies to you. Please print or type.
2. Have your physician complete the other sections. The information in this form must be based upon an examination
within three months from the date of your physician’s certification.
3. Either you or your physician may return the completed form by fax, mail, or email (see contact information above). This
form must be received by the department within three months after your physician signs it.
SECTION 1: Driver/Applicant Information
Name (First, Middle, Last)
Date of Birth
Driver’s License Number
Street Address
Telephone Number 8 a.m. – 5 p.m.
City
State
ZIP
Today’s Date
SECTION 2: History
Do you have, or have you had, any of the following conditions? Check all that apply:
Cardiovascular problems or disease
Orthopedic, musculoskeletal, bone, joint or muscle
problems or disease
Diabetes
Physical impairments
Head or spinal injuries
Seizures, blackouts, convulsions, or fainting
Mental or psychiatric problem or disease
Sleep disorders
Neurological problems or disease
Substance Use/Abuse
Please explain any conditions checked above:
Please list any other health problems:
DA-4P (03/16/2021)
Page 1 of 5
PHYSICIAN’S STATEMENT OF EXAMINATION
Michigan Department of State
P.O. Box 30810, Lansing, Michigan 48909-9832
Phone: 517-335-7051; Fax: 517-335-2189; email: MedicalForms@Michigan.gov
Michigan.gov/SOS
Reason for Referral
(to be completed by Department of State personnel or referring health care provider)
Reason for Referral:
Driver indicated a loss or impairment of consciousness within last:
6 months
12 months or more
Date:
Driver may have a medical condition that could affect safe driving within the last:
6 months
12 months or more
Name and Title of Referrer:
Signature of Referrer:
Telephone
Instructions for Driver/Applicant
1. Complete Sections 1 through 4 with all of the information that applies to you. Please print or type.
2. Have your physician complete the other sections. The information in this form must be based upon an examination
within three months from the date of your physician’s certification.
3. Either you or your physician may return the completed form by fax, mail, or email (see contact information above). This
form must be received by the department within three months after your physician signs it.
SECTION 1: Driver/Applicant Information
Name (First, Middle, Last)
Date of Birth
Driver’s License Number
Street Address
Telephone Number 8 a.m. – 5 p.m.
City
State
ZIP
Today’s Date
SECTION 2: History
Do you have, or have you had, any of the following conditions? Check all that apply:
Cardiovascular problems or disease
Orthopedic, musculoskeletal, bone, joint or muscle
problems or disease
Diabetes
Physical impairments
Head or spinal injuries
Seizures, blackouts, convulsions, or fainting
Mental or psychiatric problem or disease
Sleep disorders
Neurological problems or disease
Substance Use/Abuse
Please explain any conditions checked above:
Please list any other health problems:
DA-4P (03/16/2021)
Page 1 of 5
SECTION 3: General Questions for Driver/Applicant
1. How many traffic accidents have you been involved in while driving in the past 5 years?
None
2. Were you injured in any traffic accidents?
Yes
If yes, please describe your injuries:
Was treatment given?
Yes
No If yes, where was treatment given?
3. Describe any loss of consciousness or any impairment of consciousness in the past 5 years:
None
Did you tell your doctor about the event(s)?
Yes
If yes, what was the diagnosis for the event(s)?
4. Have you ever become lost when driving in familiar areas?
Yes
5.
Has any family member or friend made a suggestion that you not drive or limit your driving?
Yes
6.
Have you ever been told by a doctor to limit or stop driving?
Yes
7. How many times in the past 5 years have you had contact with police as a result of a traffic stop or accident?
None
8.
Do you require a passenger to assist you when driving?
Yes
9. Please list all medications you are currently prescribed and/or taking:
10. How many alcoholic drinks do you consume per day?
Per week?
Per month?
11. Have you had treatment
or a recommendation for treatment for
any of the following? :
Alcohol Use
Yes
No
Illicit Drug Use
Yes
No
Prescription Drug Use
Yes
No
12. Do you wear or use any of the following corrective lenses? Check all that apply:
Glasses
Contacts
Telescopic Lens Device
Other:
13. Do you have any progressive or degenerative diseases of the eye? Check allthat apply:
Retinitis Pigmentosis
Cataracts
Glaucoma
Macular Degeneration
Diabetic Retinopathy
Other:
14. How often do you drive at night?
Regularly
Sometimes
Never
15. How often do you drive on the freeway?
Regularly
Sometimes
Never
16. How many miles do you drive per day?
Per week?
Per month?
17. How often do you wear your seatbelt?
Always
Sometimes
Never
SECTION 4: Driver/Applicant Certification
I hereby authorize the release of information to the Department of State only for the purpose of assisting in evaluating
my
ability to safely operate a motor vehicle. I am aware that the Department of State may contact my physician for clarification or
follow-up. I certify that my responses contained in this document are true and accurate to the best of my knowledge and belief.
Driver Applicant's Signature:
If you assisted the driver/applicant with the completion of this form, please complete the following information.
Name
Telephone Number
Relationship to Driver/Applicant
Address
City
State
Zip
I am completing Sections 1 through 4 of this form at the request of the driver/applicant.
Signature:
Date:
DA-4P (03/16/2021)
Page 2 of 5
PHYSICIAN’S STATEMENT OF EXAMINATION
Instructions for Physician
1. Review statements on pages one and two. You may contact the Driver Assessment Section at 517-335-7051 for
additional information regarding the reason for referral.
2. Complete Sections 5 through 7 based upon an examination within three months from the date of your certification. Please
print or type your answers and attach additional pages if necessary.
3. Either you or the patient may return this form to the department by fax, mail, or email (see top of page 1 for contact
information). It must be received within three months after your certification.
SECTION 5: General Questions for Physician
1. How long has the patient been under your care?
Date of most recent medical exam
2. Do you have concerns about the patient’s physical or mental capability to safely operate a motor vehicle?
Yes
No
Please explain:
3. If applicable, please check the following cognitive tests that were administered to the patient and list any concerns:
Intact
Impaired
Intact
Impaired
Mini Mental State Exam
/30
Trails A&B:
Clock Drawing
Other:
Concerns:
4. If applicable, please check the following functional tests that were administered to the patient and list any concerns:
Intact
Impaired
Intact
Impaired
Rapid Pace Walk
Range of Motion – Head and Neck
Rotation Test
Manual Test of Motor Strength
Other:
Concerns:
5. Do you recommend the department request an assessment of the patient’s?
Visual Condition
Yes
No
Psychiatric/Psychological Condition
Yes
No
Substance Use
Yes
No
Other
Yes
No
If yes, please explain:
6. What types of driving restrictions, if any, do you recommend the Department of State should consider based upon the
patient’s medical condition(s) (e.g., adaptive equipment, daylight driving only, trip lengths, trip radius, etc.)?
Please specify:
7. Should the department require periodic medical evaluations to monitor changes in the patient’s condition?
Yes
No
If yes, specify condition and evaluation frequency:
8. Do you recommend an on-the-road driving evaluation?
Yes
No
DA-4P (03/16/2021)
Page 3 of 5
SECTION 6: Current Diagnoses, Medications, Treatment and Prognosis
Complete the following diagnoses sections, in the order of importance, for the medical condition(s) that may affect
the patient’s ability to safely operate a motor vehicle. Attach additional pages if necessary.
PRIMARY DIAGNOSIS
Diagnosis:
The patient’s condition is
Prescribed Medication
Dosage Start Date
(check all that apply):
Symptoms:
Episodic
Chronic
Progressive
Age at onset:
Prognosis:
Guarded
Poor
Fair
Good
Excellent
Supporting facts for prognosis:
Treatment or therapy plan:
Is the condition adequately controlled with medication, treatment or therapy?
Yes
No
N/A
Comments:
Is another medical specialist involved in treatment of this condition?
Yes
No
If yes, name and specialty:
Has the patient reported a loss of, or impairment of consciousness?
Yes
No
If yes, please describe:
Date of last episode:
Frequency:
If the patient experienced an episode or medical event, is there reasonable medical evidence it was
due to a medically supervised change in medication or dosage?
Yes
No
N/A
If yes, please explain:
Comments:
SECONDARY DIAGNOSIS
Diagnosis:
The patient’s condition is
Prescribed Medication
Dosage Start Date
(check all that apply):
Symptoms:
Episodic
Chronic
Progressive
Age at onset:
Prognosis:
Guarded
Poor
Fair
Good
Excellent
Supporting facts for prognosis:
Treatment or therapy plan:
Is the condition adequately controlled with medication, treatment or therapy?
Yes
No
N/A
Comments:
Is another medical specialist involved in treatment of this condition?
Yes
No
If yes, name and specialty:
Has the patient reported a loss of, or impairment of consciousness?
Yes
No
If yes, please describe:
Date of last episode:
Frequency:
If the patient experienced an episode or medical event, is there reasonable medical evidence it was
due to a medically supervised change in medication or dosage?
Yes
No
N/A
If yes, please explain:
Comments:
DA-4P (03/16/2021)
Page 4 of 5
TERTIARY DIAGNOSIS
Diagnosis:
The patient’s condition is
Prescribed Medication
Dosage Start Date
(check all that apply):
Symptoms:
Episodic
Chronic
Progressive
Age at onset:
Prognosis:
Guarded
Poor
Fair
Good
Excellent
Supporting facts for prognosis:
Treatment or therapy plan:
Is the condition adequately controlled with medication, treatment or therapy?
Yes
No
N/A
Comments:
Is another medical specialist involved in treatment of this condition?
Yes
No
If yes, name and specialty:
Yes
No
Has the patient reported a loss of, or impairment of consciousness?
If yes, please describe:
Date of last episode:
Frequency:
If the patient experienced an episode or medical event, is there reasonable medical evidence it
Yes
No
N/A
was due to a medically supervised change in medication or dosage?
If yes, please explain:
Comments:
SECTION 7: Physician’s Certification
Name (First, Middle, Last)
M.D. or D.O.
Professional License Number
Address
City
State
ZIP
Telephone Number
Type of Practice or Medical Specialty
As of this date, I certify that I have reviewed Sections 1 through 4 and completed Sections 5 through 7 and that this Physician’s
Statement of Examination is true to the best of my knowledge and belief based on information obtained from the patient, the
patient’s known medical history, and a patient examination. I understand that the decision to grant, suspend, or reinstate an
individual’s driving privileges rests solely with the Department of State, which may consider other facts or conditions when
making this decision.
Physician’s Signature:
Date:
(Required)
Sign below if this form was completed by a psychologist, physician’s assistant, or nurse practitioner.
PSY/PA/NP Signature:
Date:
For Driver Assessment Use Only
FAVORABLE
COME-UP DATE
RESTRICTION
MUST PASS
UNFAVORABLE
QUESTIONABLE
REFER FOR REEXAMINATION
NEED ADDITIONAL INFORMATION
MEDICAL
VISION
SKILLS TESTING
SUBSTANCE USE DISORDERS EVALUATION
REVIEWED BY:
DATE:
DA-4P (03/16/2021)
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