Free Medical Examination Louisiana Form

HISTORY

ORTHOPAEDIC HEARING VISION

1.Patient’s Name: ____________________________________________________ Date of Birth: _____________________

2.Does patient have any medical or physical disorders? _________ If yes, list the medical or physical disorders __________

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3.Is patient taking any medication? _________ If yes, list current medication and dosage __________________________

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4.Has patient had any past surgical procedures? _________ If yes, list the past surgical procedures ___________________

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5.Has patient had any illness that could affect the ability to operate a motor vehicle safely? __________ If yes, describe the illness __________________________________________________________________________________________

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6.Has patient’s driving privileges ever been withdrawn for a medical or physical disorder? ____________________________

1.What is patient’s visual acuity without corrective lens? Right eye 20/________ Left eye 20/_______ Both eyes 20/_______

2.Are corrective lens worn? ______ If yes, with corrective lens: Right eye 20/ _____ Left eye 20/ _____ Both eyes 20/ _____

3.What are patient’s peripheral vision fields? ________________ Right eye ________________ Left eye _______________

Applicant can recognize and distinguish among traffic control signals and devices showing standard red, green and amber?

□ Yes □ No

1.Does the patient have any hearing impairment? _______ If yes, describe the hearing impairment ____________________

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2.Is a hearing aid worn? _________ If yes, does it give sufficient correction? ______________________________________

1.Does patient have any amputation or skeletal deficits that could interfere with the ability to operate a motor vehicle safely?

_____ If yes, describe the deficits in detail ________________________________________________________________

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2.Does patient have stiff or frail joints? _______ If yes, describe ________________________________________________

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3.Does patient have spastic or paralyzed muscles? _______ If yes, describe ______________________________________

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4.Does patient have any orthopedic appliances or supports? _______ If yes, list any device or support and how long used __

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5.Does this device provide adequate compensation for operating a motor vehicle safely? ____________________________

NEUROLOGICAL CARDIOPULMONARY

MENTAL

DIABETES

3.

1.Does patient have angina?______ If yes, when does it occur?_____strenuous activity_____normal activity_____at rest_____

2.Does patient have dyspnea?_____If yes, when does it occur?_____strenuous activity_____normal activity_____at rest_____

3.Does patient have syncope?_____if yes, what is the frequency?__________duration___________last occurance_________

4.Does patient have dizziness?______ describe______________________________________________________________

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5.What is patient’s blood pressure? 1st reading __________________________ 2nd reading __________________________

6.What is patient’s pulse? Rate __________________________________ Rhythm __________________________________

7.Has patient had cardiovascular catheterization or surgery? ______ If yes, describe _________________________________

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List medications and dosage: ____________________________________________________________________________

1.Does patient have epilepsy? ______If yes, what type of seizures? _________________ Date of last seizure? ____________

Are seizures completely controlled? _______ Is patient under regular medical care? ________________________________

What are the anticonvulsant serum blood levels? ____________________________________________________________

2.Does patient have any signs of Parkinsonism? ______ If yes, describe condition and severity _________________________

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Is coordination normal? _______ If no, describe _____________________________________________________________

3.Does patient have any neurological disorder? ______ If yes, describe ___________________________________________

List medications and dosage: ____________________________________________________________________________

Is patient reliable in taking medication and following medical regimen? _____________________________________________

1.Does patient have symptoms of any mental disorder? ______ If yes, describe condition and severity at present ___________

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2.Has patient ever been treated in a mental hospital? _______ If yes, where and when _______________________________

What was diagnosis and cure? __________________________________________________________________________

3.Does patient use alcohol or drugs? ______ If yes, describe usage ______________________________________________

4.Is patient mentally deficient? ______ If yes, what was highest grade attained in school? ________ age at attainment? _____

5.Does patient have sufficient regard for his/her personal safety as well as that of others to operate a motor vehicle safely? Give details _________________________________________________________________________________________

6.Is patient likely to act on sudden impulse without regard for the consequences of his/her behavior? ____________________

Give details _________________________________________________________________________________________

7.On the basis of your examination and/or knowledge of this patient, do you recommend periodic psychiatric examinations? Give details _________________________________________________________________________________________

List medications and dosage: ____________________________________________________________________________

1.Does patient have a history of diabetes? _______ If yes, is insulin taken? ______ is oral medication taken? ______________

2.What are patient’s laboratory studies? recent urine sugars __________________ recent blood sugars __________________

3.Has patient had any occurrences of diabetic coma? ________ If yes, give dates ___________________________________

4.Has patient had any occurrences of insulin shock? ________ If yes, give dates ____________________________________

5.Does patient have associated abnormalities? visual_______renal_______vascular_______neurological_______other______ If yes, describe _______________________________________________________________________________________

6.Does patient have hypoglycemia? _______ If yes, describe treatment ___________________________________________

List medications taken and dosage: _______________________________________________________________________

Is patient reliable in taking diabetes medication? ______________________ Is diabetes controlled? ______________________

TO BE SIGNED BY PATIENT