HTML Preview Medical Evaluation Report page number 1.
Universal Medical Evaluation/Progress Report
Department of Motor Vehicles
Agency of Transportation
120 State street
Montpelier, Vermont 05603-0001
802.828.2000
888.99-VERMONT
dmv.vermont.gov
**THIS EVALUATION MUST BE COMPLETED IN FULL OR IT WILL BE RETURNED**
ANY MEDICAL CHARGES INCURRED ARE THE RESPONSIBILITY OF THE PATIENT
Indicate Reason for Evaluation
Complete Sections A, B, D & E
if
you are
selecting one of the
four reasons below. See front and back of form.
Applying for a Vermont License/Permit
School Bus Endorsement (Type II)
Department Request
New/Update Medical Condition
Complete ALL Sections if requesting a DISABLED
PLACARD
OR
PLATES.
See front and back of form.
Disabled Parking Placard (must also submit a completed Disabled Parking Placard Application ~ VD-120)
Disabled Parking Plate (must also submit a completed Registration, Tax and Title Application ~ VD-119)
**
Parking Placard Applicants: The Information In This Medical May Be Considered In Determining Your License Status
**
SECTION A - To Be Completed By Applicant
Patient’s Name:
Patient’s
Mailing
Address:
Street / Road / Box Number
City / State / Zip Code
Physical Address – If Different From Mailing Address
Gender:
Check If The Above Is A Change To Your:
Mailing Address Physical Address
Date Of Birth
Social Security Number
VT Driver License/Id Number
If This Is A Name Change, List Former Name:
I certify that the information contained above is true, complete and correct to the best of my knowledge. Statements and warrants herein are certified under
penalty of 23 V.S.A. §202 & §203.
APPLICANT’S SIGNATURE:
SECTIONS B, C, D & E – To Be Completed By Medical Examiner
SECTION B
1.
Patient has been under my care for
years.
2.
Check any of the following conditions that apply:
Seizures
Cancer
Spinal Injury
Hypertension
Diabetes
COPD
Arthritis/Degenerative Joint Disease
Amputation:
Permanent Disability/Condition:
Specify:
Psychiatric Disorder:
Arm:
Left
Right
Specify:
Leg:
Left
Right
Describe cause and extent (example: at
elbow, below knee) of amputation:
3.
Blood pressure reading is required for all school bus driver medicals.
For other licensed drivers, only indicate if a medical condition exists.
Systolic:
Diastolic:
DEPARTMENT USE ONLY SECTION
MEDICAL DATE: MM/DD/YYYY
RATER #:
TRANSACTION TYPE:
TYPE:
ADD
A – SCHOOL BUS
UPDATE
B – NOT STABLE
D – STABLE
VS-113 5M 12/2016 MTC