Medical Condition Report

 Alcohol Dependence  Visual Field Impairment  Drug Dependence  Diabetes or Hypoglycemia - Uncontrolled  Seizure(s)-Cerebral  Other metabolic diseases (specify)  Seizure(s)-Alcohol related  Mental or Emotional Illness-Unstable  Heart disease with Pre-syncope/Syncope/Arrhythmia  Dementia or Alzheimer s  Blackout or Loss of consciousness or Awareness  Sleep Apnea-Uncontrolled  Stroke/TIA or head injury with significant deficits  Narcolepsy-Uncontrolled  Both Visual Acuity and Visual Field Impairment  Motor Function/Ability Impaired  Visual Acuity Impairment  Other (specify): Optional To expedite your patient s file, please provide further elaboration of clinical condition (if available) or attach as a separate report: Diagnosis Other Relevant Clinical Information (i.e current status - including results of investigations, medication(s), treatment and prognosis) and whether or not the condition is a serious risk to road safety, threat to road safety is unknown or condition is temporary - weeks/months..