Scribd Logo
Upload

Welcome to Scribd!

  • MTO Medical Condition Report

    Uploaded by

    ec
    150 views2 pages

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    Report this Document

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    150 views2 pages

    MTO Medical Condition Report

    Uploaded by

    ec

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as pdf or txt
    of 2

    Ministry of Transportation Medical Condition Report

    Fee Schedule Code


    K035

    Save Form Print Form Clear Form

    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 *

    City/Town/Village * Postal Code Male * Driver's Licence Number (if available):


    Female *
    Part 2. Practitioner's Information
    Practitioner's Last Name * Practitioner's First Name *

    Practitioner's Address
    Unit Number Street Number * Street Name *

    City/Town/Village * Province * Postal Code

    I am this person's: Family/Treating Physician ER Physician Nurse Practitioner Occupational Therapist


    Urgent Care/Walk In Clinic Physician Other
    I have provided my patient or their legal representative with a copy of this report. Yes No
    I approve of the ministry releasing this report to the patient or their legal representative if requested. Yes No
    I wish to be notified if my patient requests a copy of this report from the ministry, as releasing this report may Yes No
    threaten the health or safety of the patient or another individual.
    Practitioner's Signature Date of Report Examination (yyyy/mm/dd)

    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
    5108E (2019/05) © Queen's Printer for Ontario, 2019 Disponible en français Page 1 of 2
    Patient Information
    Last Name * First Name * Middle Init. Date of Birth (yyyy/mm/dd) *

    Seizure due to:


    Alcohol Withdrawal Aneurysm Brain Tumour Epilepsy Stroke Intracranial Haemorrhage
    Other (Specify)
    Hypoglycaemia requiring intervention of a third party or producing loss of consciousness
    CVA resulting in:
    Physical Impairment Cognitive Impairment Visual Field Impairment. (If checked please complete section 4)
    Other (Specify)
    3. Motor or Sensory Impairment
    This patient has or appears to have a condition or disorder resulting in severe motor impairment that affects: coordination, muscle
    strength and control, flexibility, motor planning, touch or positional sense.
    Due to:
    Central Nervous System Impairment
    CVA Parkinson’s Disease Multiple Sclerosis Spinal Cord Injury Other (Specify)
    Peripheral Nervous System Impairment
    ALS Nerve Injury Polyneuropathy Other (Specify)
    Other (Specify)
    4. Visual Impairment
    This patient has or appears to have:
    Best corrected visual acuity below 20/50 with both eyes open Without With
    and examined together Eyes Visual Field
    Correction Correction
    A visual field that is less than 120 continuous degrees along
    Right 20/ 20/ Full Restricted
    the horizontal meridian, or less than 15 continuous degrees
    above and below fixation, or less than 60 degrees to either Left 20/ 20/ Full Restricted
    side of the vertical meridian, including hemianopia.
    Diplopia that is within 40 degrees of fixation point (in all Combined 20/ 20/ Full Restricted
    directions) of primary position, that cannot be corrected using
    prism lenses or patching.
    Due to (check any that apply):
    Retinitis Pigmentosa Glaucoma Diabetic Retinopathy CVA Acquired Brain Injury Unknown
    Other (Specify)

    5. Substance Use Disorder


    This patient has or appears to have a diagnosis of an uncontrolled substance use disorder, excluding caffeine and nicotine, and is
    non-compliant with treatment recommendations.
    Alcohol Other Substances (Specify)
    Recommended form of treatment is: Outpatient Intensive Residential

    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)

    7. Discretionary report of medical condition, functional impairment or visual impairment


    In the opinion of the prescribed person, this patient has or appears to have a medical condition, functional impairment or visual
    impairment that may make it dangerous for the person to operate a motor vehicle and is being reported pursuant to Section 203(2)
    of the Highway Traffic Act.
    Please describe condition(s) or impairment

    5108E (2019/05) Page 2 of 2

    You might also like