Driver'S Medical Examination Report - Nova Scotia
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1
2Driver’s Medical Examination Report
If you have any questions, please contact the Medical section at 902-424-5732. for additional information, you may also
refer to our website at: novascotia.ca/snsmr/rmv/licence/medicals.asp.
Mailing Address: Medical section, 1505 barrington street, 9N, Halifax Ns, b3J 3K5
Fax: 902-424-0772
PART 1: Patient Consent for Physician to Report Medical Information
Phone: Home (
Work (
Name:
)
)
___ ___ ___ – ___ ___ ___ ___
___ ___ ___ – ___ ___ ___ ___
____________________________________________________________________________________________
_____
_____
Cell (
Address:
)
___ ___ ___ – ___ ___ ___ ___
_________________________________________________________________________________________
_____
______________________________ Postal code: ____________
I authorize any physician, hospital or medical clinic to release to the
Driver’s Licence Master No.:
Department any information concerning my medical condition.
___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___
Date of birth (DD/MM/YYYY):
_____________________________________________________________
m m m m m m m m
class of licence applied for (check one):
________________________________________________________
_________________________________________
1
2
3
4
5
6
7
8
PAtIeNt’s sIGNAtUre
DAte (DD/MM/YYYY)
PART 2: Vision – Check and complete applicable boxes
m
m
VISUAL ACUITY
Meets AcUItY for LIceNce cLAss
VISUAL FIELD
Meets fIeLD for LIceNce cLAss
(With or without corrective lenses)
m
Uncorrected r __________
L _________ both _____________
Abnormal. explain
____________________________________________________________________
m
corrected
r ___________
L _________ both _____________
ocular condition that could affect driving. explain:
________________________
m
______________________________________________________________________________________________________
Requires visual correction
FIELD: class 3, 5, 6, 7 and 8: 120 degrees horizontal, both eyes opened
ACUITY: class 3, 5, 6, 7 and 8 not less than 20/40 (6/12) in better eye.
class 1, 2 and 4 not less than 20/30 (6/9) in the better eye,
and examined together.
poorer eye not less than 20/50 (6/15).
class 1, 2 and 4: 120 degrees horizontal in each eye.
m
COLOUR RECOGNITION
Meets coLoUr recoGNItIoN for LIceNce cLAss
class 1, 2 and 4 - Able to accurately identify the colours red, green and amber.
PART 3: Examination Report – Check Nothing to Report or check and complete applicable conditions(s)
m
m
A – VASCULAR
B – CENTRAL NERVOUS SYSTEM
NotHING to rePort
NotHING to rePort
q
q
1. coronary Artery Disease
1. cVA/tIA: Date _____________________________________
________________________________________________________
q
q
m
2. Angina Pectoris
2. seizure disorder
Diagnosis of epilepsy.
____________________________________________________________________
canadian cardiovascular society functional class
Date of last seizure ______________________________
m
m
m
m
m
m
Medication required?
Yes
No
class 1
class 2
class 3
class 4
q
q
3. syncope
type: ___________________________________
3. Myocardial Infarction: Date
____________________________________________________
q
m
single episode: Date ______________________________
4. congestive Heart failure
m
q
recurrent
5. Arrhythmia:
__________________________________________________________________________
q
q
4. sleep Disorder:
6. Peripheral Vascular Disease ___________________________
m
m
m
q
osA. Treated?
Yes How: __________
No
7. Aneurysm: Location:
Size:
_______________
__________________________________
m
m
m
Narcolepsy
Treated?
Yes
No
q
8. Heart surgery
q
5. stable Deficit: _____________________________________
m
Angioplasty: Date
_____________________________________________________________
________________________________________________
m
cAbG: Date
_____________________________________________________________________
q
m
6. Progressive Disorder (ALs, Parkinsons, Ms):
Pacemaker: Date
_____________________________________________________________
m
IcD: Insertion Date
________________________________________________
___________________________________________________________
q
Last Discharge Date
7. Vestibular Disorder: _________________________________
________________________________________________________
m
q
transplant: Date
8. cognitive Impairment: ______________________________
_______________________________________________________________
m
LVAD
________________________________________________
q
9. other:
_________________________________________________________________________________
MMse score: ______________ Date __________________
( D D / M M / Y Y Y Y )
Page 1 of 2
novascotia.ca/snsmr/rmv/licence
As of october 2014
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