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MTO Medical Condition Report
MTO Medical Condition Report
Report by a prescribed person in compliance with Subsection 203(1) or 203(2) of the Highway Traffic Act.
Please complete in full.
Mail or fax to: Medical Review Section, 77 Wellesley Street West, Box 589, Toronto ON M7A 1N3
Fax Number: 416-235-3400 or 1-800-304-7889 Telephone Number: 416-235-1773 or 1-800-268-1481
Fields marked with an asterisk (*) are mandatory. When a report of a mandatory condition is made it will result in a licence
suspension.
Part 1. Patient Information
Last Name * First Name * Middle Init. Date of Birth (yyyy/mm/dd) *
Current Address
Unit Number Street Number * Street Name or Lot * PO Box Province *
Practitioner's Address
Unit Number Street Number * Street Name *
Part 3. Medical Condition, Functional Impairment or Visual Impairment - Please check all diagnoses that apply.
1. Cognitive Impairment
This patient has or appears to have a disorder resulting in cognitive impairment that affects attention, judgement and problem
solving, planning and sequencing, memory, insight, reaction time or visuospatial perception, and results in substantial limitation of
the person’s ability to perform activities of daily living.
Due to: Dementia Brain Injury Unknown Other (Specify)
2. Sudden Incapacitation
This patient has or appears to have a disorder that has a moderate or high risk of sudden incapacitation, or that has resulted in
sudden incapacitation and that has a moderate or high risk of recurrence.
Due to:
Aortic aneurysm - at the stage of imminent rupture
Cerebral aneurysm
Heart disease with Pre-syncope/syncope/arrhythmia
Narcolepsy with uncontrolled cataplexy or daytime sleep attacks
Obstructive sleep apnea – Untreated or Unsuccessfully Treated with Apnea-hypopnea index (AHI) of ≥20 with excessive
daytime sleepiness
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Patient Information
Last Name * First Name * Middle Init. Date of Birth (yyyy/mm/dd) *
6. Psychiatric Illness
This patient has or appears to have a condition or disorder currently involving any of the following: acute psychosis, severe
abnormalities of perception, or has a suicidal plan involving a vehicle or an intent to use a vehicle to harm others.
Due to: Major Depressive Disorder Bipolar Disorder Anxiety Disorder Personality Disorder
Schizophrenia or other Psychotic Disorder Other (Specify)