MED 2 (02/25/2017)

CUSTOMER MEDICAL REPORT

Purpose: Use this form to request medical information from your physician, physician assistant or nurse practitioner.
Instructions: Follow the detailed INSTRUCTIONS printed on page 2. Complete the Customer Information and Information Release
Approval sections on this page. Take the entire MED 2 and DMV letter to your physician, physician assistant or nurse
practitioner to complete the sections that pertain to your medical condition. Part F must be completed by your physician,
physician assistant or nurse practitioner. Note: Any charges related to or incurred as part of the completion of this form
are the customer's responsibility.

CUSTOMER INFORMATION
NAME (Last) (First) (MI) (Suffix) CUSTOMER NUMBER (from your driver's license) or SSN

RESIDENCE/HOME ADDRESS Check if this is a new address, your address will be changed
on DMV's system.
CITY STATE ZIP CODE CITY OR COUNTY OF RESIDENCE

MAILING ADDRESS (if different from above)

CITY STATE ZIP CODE DAYTIME TELEPHONE NUMBER

BIRTH DATE (mm/dd/yyyy) GENDER WEIGHT HEIGHT

MALE FEMALE lbs FT IN
Describe, in detail, your medical condition.

Do you take prescription/non-prescription medications? YES NO If Yes, list below. (attach a separate sheet if more space is required)

NON-PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN

Have you ever experienced a blackout, seizure, loss of consciousness, or syncope? DATE (mm/dd/yyyy) Did the episode result in a motor vehicle crash?
YES NO If Yes, enter date of last episode. YES NO

Explain what happened during the episode.

COMMERCIAL DRIVER LICENSE DISABILITY WAIVER OR HAZARDOUS MATERIALS VARIANCE

Are you applying for a commercial driver license disability waiver or a hazardous materials variance? YES NO
If YES, a CDL Disability Waiver or Hazardous Materials Variance Application (MED 30) must also be submitted.

INFORMATION RELEASE APPROVAL

I authorize ________________________________________________ and/or_______________________________________________________,
a licensed medical provider to complete this Customer Medical Report, submit it to DMV and, if necessary to provide further clarification or information
to DMV about my physical and/or mental condition. I consent to DMV using this information to arrive at a decision concerning my ability to safely
operate a motor vehicle. I also authorize DMV to use the above customer information to correctly identify my records on file in accordance with the
Virginia Privacy Protection Act of 1976. I understand that Virginia Code § 46.2-208(b)(1) prohibits DMV from releasing medical data to anyone other
than a physician, physician assistant or nurse practitioner
CUSTOMER SIGNATURE AND AUTHORIZATION (parent must sign for a minor) DATE (mm/dd/yyyy)
 MED 2 (02/25/2017)
Page 2

CUSTOMER MEDICAL REPORT

INSTRUCTIONS

Purpose: Use these instructions to complete the Customer Medical Report (MED 2).

CUSTOMER INSTRUCTIONS
1. Review all correspondence received from the Department of Motor Vehicles (DMV) regarding concerns about your
ability to safely operate a motor vehicle.
n If you received an Official Notice/Order of Suspension, you must provide DMV with the required Customer
Medical Report (MED 2), prior to the effective date noted in the Notice/Order to avoid having your driving
privilege suspended.
n If your driving privilege is suspended, you will be required to provide proof of legal presence in order to reinstate
your driver's license, if you have not already provided proof.

2. Complete the sections of the MED 2 titled “Customer Information” and “Information Release Approval”. Be sure to
provide your signature at the end of the “Information Release Approval” section.

3. Take the entire MED 2 and your DMV letter to your medical provider at the time of your medical examination.

4. Request your medical provider to complete the parts of the MED 2 that pertain to your medical condition(s) and
Part F and return the report to DMV (following medical provider instructions below).
n The medical examination must be conducted after the issue date of your Official Notice/Order of Suspension.
n If you were involved in a recent motor vehicle crash or have experienced a recent blackout, seizure or loss of
consciousness, the MED 2 report must reference these incidents and/or events.

Note: you will be notified of any decisions regarding your driving privilege based on:
m Medical and other related information received from your medical provider,
m DMV driver license test results and/or a certified independent driver rehabilitation evaluation (if required),
m DMV medical review policies and guidelines as established in collaboration with the DMV Medical Advisory Board.

5. If you have questions related to DMV's requirement for you to submit a MED 2, you may contact DMV Medical
Review Services:
n Mail - send your request in writing to Medical Review Services at the address listed at the top of this form
n Telephone - (Voice) 1-804-367-6203 or (Deaf/Hearing Impaired only) 1-800-272-9268
 MED 2 (02/25/2017)
Page 3
CUSTOMER MEDICAL REPORT
INSTRUCTIONS

MEDICAL PROVIDER INSTRUCTIONS

1. The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your
patient's ability to safely operate a regular motor vehicle and/or commercial motor vehicle. DMV is concerned about
any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion
m judgment/cognitive function m reaction time
2. DMV may have requested these documents for one of three reasons:
n DMV received a crash report, Medical Review Request Form, or a court document that requires a medical
evaluation. Please refer to the customer explanation letter that describes the issue of concern that needs to be
addressed. Each form, A-E, has a section to complete regarding the issue. Please supply a medical opinion on
the area of concern and attach any relevant lab work or test results.
If your patient was involved in a recent motor vehicle crash or has experienced a recent blackout, loss of
consciousness, or seizure, the MED 2 must include specific information that may have contributed to the
incident(s) and/or event(s).
n DMV is requesting these forms for a patient we have under periodic review. Please be sure to address the
patient's ongoing stability, any episode of instability, or any decline in the patient's condition. Please note any
new conditions that may interfere with safe driving.
n A patient self-reported on their application a medical condition or a medication that may indicate a medical
condition that DMV evaluates for driver safety.

3. Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's
medical condition(s).
n For medical conditions, complete one or more of the following specific report sections:
m Neurological/Musculoskeletal - Part A & F
m Metabolic - Part B & F
m Cardiovascular - Part C & F
m Pulmonary - Part D & F
m Psychiatric/Substance Abuse - Part E & F
NOTE: Only one Part F is required if the same medical provider completes multiple report sections.

4. In lieu of completing the MED 2, you may submit a letter, note or copies of records as long as the information you
submit addresses all of the information requested on the MED 2 including your determination on the patient's ability
and safety to drive.

5. Return the completed MED 2 to DMV by faxing it to DMV Medical Review Services at (804) 367-1604 or (804)
367-0520.

6. For additional information on DMV's medical review process, you may refer to www.dmvnow.com under "Citizen
Services", then "Medical Information", or contact Medical Review Services at 804-367-6203.
 Customer Medical Report MED 2 (02/25/2017)
Page 4
NAME (Last) (First) (MI) (Suffix) BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER or SSN

The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time

Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.

PART A - NEUROLOGICAL/ MUSCULOSKELETAL REPORT (must also complete Part F)

N/A for this customer
Length of time individual has been your patient. Have you examined this individual during the last six months? EXAMINATION DATE (mm/dd/yyyy)
YEARS MONTHS YES NO IF Yes, enter examination date.
DIAGNOSIS(ES) (In order of severity or by current treatment)

Are there any complications related to this/these condition(s)? YES NO If Yes, explain.

Has the patient been hospitalized for the above condition(s) within the past year? YES NO If Yes, list dates hospitalized and status upon discharge.

Was the hospitalization voluntary? YES NO

Does the patient have a history of seizures? YES NO If Yes, provide date of each episode and reason(s).

Indicate the risk for further episodes.

DATE OF CRASH (mm/dd/yyyy)

Did any seizure result in a motor vehicle crash? YES NO If Yes, enter date of crash.

BLOOD TEST RESULTS

Was the last medication blood serum level within acceptable range? YES NO If No, provide results of blood test.

Did the patient have a blackout or syncope? YES NO If so, what was the cause? (Please enclose documentation to support the cause; such as results of lab
work and blood pressures to support dehydration, high fever, etc.)

Does the patient have any motor deficits/nerve problems that would impair his/her ability to drive? YES NO

Does the patient have any other neurological condition(s) that might affect his/her driving? YES NO If Yes, describe the condition(s) and its effect on the
patient's driving.

Does the patient have any chronic conditions, chronic pain syndromes, fibromyalgia or any movement disorders? YES NO If Yes, specify.

Is the patient prescribed medication for chronic pain or long-acting narcotics? YES NO If Yes, list the medication(s).

Does the patient have the use of all extremities? YES NO If No, which extremities are impaired?

Does the patient suffer from peripheral neuropathy? YES NO If Yes, which extremities are impaired?

Current blood levels of anticonvulsant medication TEST DATE (mm/dd/yyyy) Results of most recent EEG

Does the neuropathy affect the patient's ability to safely operate a motor vehicle? YES NO

Does the patient suffer from muscle spasms? YES NO

Does the patient have full range of motion of the head and neck? YES NO If No, describe range of motion.

Is adaptive equipment recommended? YES NO If Yes, what type of adaptive equipment does the patient require?

If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.

Go to Part F
 MED 2 (02/25/2017)

Customer Medical Report Page 5

NAME (Last) (First) (MI) (Suffix) BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER or SSN

The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time

Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.

PART B - METABOLIC REPORT (must also complete Part F)

N/A for this customer
Length of time individual has been your patient. Have you examined this individual during the last six months? EXAMINATION DATE (mm/dd/yyyy)
YEARS MONTHS YES NO IF Yes, enter examination date.
DIAGNOSIS(ES) (In order of severity or by current treatment)

Are there any complications related to this/these condition(s)? YES NO If Yes, explain.

Has the patient been hospitalized for the above condition(s) within the past year? YES NO If Yes, list dates hospitalized and status upon discharge.

Was the hospitalization voluntary? YES NO

Does the patient have diabetes or any other metabolic condition(s) that might affect vehicle operation? YES NO If Yes, indicate condition.

Do any complications or associated conditions exist? YES NO If Yes, explain.

Does this patient have hypoglycemic reactions? YES NO If Yes, provide dates and reasons.

Did the hypoglycemic reaction(s) result in a motor vehicle crash(es)? YES NO

Does this patient demonstrate how to counter a hypoglycemic reaction? YES NO If Yes, explain how.

Has this patient been hospitalized for treatment of diabetes/hypoglycemia or complications in the past year? YES NO If Yes, explain

Does the patient monitor his/her blood sugar? YES NO If Yes, how often?

Attach the following information/documents, If you suffered a hypoglycemic event, please ensure that your blood sugar logs reflect the last 15 days and your A1C results are
drawn after the incident occurred and within the last 30 days.
Blood Sugar Logs (15 days) Attached
Hemoglobin A1C Results (30 days) Attached

If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.
Go to Part F
 MED 2 (02/25/2017)
Customer Medical Report Page 6

NAME (Last) (First) (MI) (Suffix) BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER or SSN

The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time

Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.

PART C - CARDIOVASCULAR REPORT (must also complete Part F)

N/A for this customer
Length of time individual has been your patient. Have you examined this individual during the last six months? EXAMINATION DATE (mm/dd/yyyy)
YEARS MONTHS YES NO IF Yes, enter examination date.
DIAGNOSIS(ES) (In order of severity or by current treatment)

Are there any complications related to this/these condition(s)? YES NO If Yes, explain.

Has the patient been hospitalized for the above condition(s) within the past year? YES NO If Yes, list dates hospitalized and status upon discharge.

Was the hospitalization voluntary? YES NO

Does the patient have an implantable cardioverter defibrillator? YES NO If Yes, give implant date.

Has the unit discharged since the implant? YES NO If Yes, describe the patient's condition at the time and date of discharge.

Does the patient have a ventricular assist device system? YES NO If Yes, when was this device implanted?

Has the patient had any of the following:

Cardiovascular surgery and/or other procedures? YES NO If Yes, explain and give dates.

Syncope? YES NO If Yes, explain and give dates. Attach the following information/documents:
Results of Event Monitor
Results of Holter Monitor
Results of Tilt-table Test
Results of EKG

Fatigue with exertion? YES NO Fatigue at rest? YES NO

Dyspnea with exertion? YES NO If Yes, explain and give dates.

Dyspnea at rest? YES NO If Yes, explain and give dates.

Pulmonary symptoms? YES NO If Yes, explain and give dates.

If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.

Go to Part F
 MED 2 (02/25/2017)
Customer Medical Report Page 7

NAME (Last) (First) (MI) (Suffix) BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER or SSN

The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time

Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.

PART D - PULMONARY REPORT (must also complete Part F)

N/A for this customer
Length of time individual has been your patient. Have you examined this individual during the last six months? EXAMINATION DATE (mm/dd/yyyy)
YEARS MONTHS YES NO IF Yes, enter examination date.
DIAGNOSIS(ES) (In order of severity or by current treatment)

Are there any complications related to this/these condition(s)? YES NO If Yes, explain.

Has the patient been hospitalized for the above condition(s) within the past year? YES NO If Yes, list dates hospitalized and status upon discharge.

Was the hospitalization voluntary? YES NO

Is oxygen use required? YES NO If Yes, describe treatment regimen and provide number of liters.

Fatigue with exertion? YES NO Fatigue at rest? YES NO

Dyspnea with exertion? YES NO If Yes, explain and give dates.

Dyspnea at rest? YES NO If Yes, explain and give dates.

Syncope from cough? YES NO If Yes, explain cause and resolution.

Does the patient have a diagnosis of sleep apnea, narcolepsy, or other sleep disorder?
YES mild moderate severe (describe the treatment and submit a CPAP report for moderate to severe sleep apnea).
NO

Does the pulmonary disease prevent activities of daily living? YES NO If Yes, identify.

Has patient been compliant with treatment to the extent that the symptoms are controlled? YES NO

Pulse oximetry room air oxygen

Can the patient maintain O2 Saturation level of 90% or higher when driving? YES NO

Attach the following information/document if available

Results of pulmonary function test
Results of sleep study
If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.

Go to Part F
 MED 2 (02/25/2017)
Customer Medical Report Page 8

NAME (Last) (First) (MI) (Suffix) BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER or SSN

The Department of Motor Vehicles (DMV) is seeking information that will allow us to make a decision regarding your patient's ability to safely operate a
regular motor vehicle and/or commercial motor vehicle. DMV is concerned about any condition(s) and/or use of medication(s) which may result in impaired:
m level of consciousness/alertness m vision/perception m motor skills/range of motion m judgment/cognitive function m reaction time

Based on the examination that you conduct, please complete the parts of the MED 2 that pertain to your patient's medical condition(s) and Part F.

PART E - PSYCHIATRIC/SUBSTANCE ABUSE REPORT (must also complete Part F)

N/A for this customer
Length of time individual has been your patient. Have you examined this individual during the last six months? EXAMINATION DATE (mm/dd/yyyy)
YEARS MONTHS YES NO IF Yes, enter examination date.
DIAGNOSIS(ES) (In order of severity or by current treatment)

Are there any complications related to this/these condition(s)? YES NO If Yes, explain.

Has the patient been hospitalized for the above condition(s) within the past year? YES NO If Yes, list dates hospitalized and status upon discharge.

Was the hospitalization voluntary? YES NO

Has the patient been hospitalized in the past year for a mental/emotional condition? YES NO If Yes, give admission date(s), reason(s) for admission and date
(s) of discharge.

Does the patient have a condition, which results in one or more of the impairments listed below? YES NO If Yes, check all that apply.
Poor decision-making/problem-solving skills Hallucinations/delusions Poor/impaired judgement
Memory loss, Cognitive Extremely aggressive/destructive behavior Dementia/confusion
Poor impulse control/extremely impulsive Emotional or behavioral instability

Identify current treatment program(s), counseling, medications, etc.

Attach the following information/documents, (if available):

MMSE attached not available
Neuropsychological Exam attached not available

Is patient CURRENTLY undergoing OR has patient successfully completed drug/alcohol treatment? YES NO If Yes, please provide name of program.

Has the patient been compliant with substance abuse treatment? YES NO

Attach the following information/documents:

Results of drug/alcohol screening
Report from substance abuse counselor
Recommendations:

Did the patient experience seizure(s) related to withdrawal? YES NO If Yes, give date(s).

If your patient is being seen for a particular incident, crash , or report provided to DMV, please provide relevant specific contributing information here.

Go to Part F
 Customer Medical Report MED 2 (02/25/2017)
Page 9
(MUST BE COMPLETED BY PHYSICIAN, PHYSICIAN ASSISTANT OR NURSE PRACTITIONER)
NAME (Last) (First) (MI) (Suffix) BIRTH DATE (mm/dd/yyyy) CUSTOMER NUMBER or SSN

PART F - GENERAL RECOMMENDATIONS

FIRST MEDICAL PROVIDER
Is the patient's condition(s) stable? YES NO If No, explain. Is the patient compliant with treatment? YES NO If No, explain:

Does the patient experience side effects of medications, which are likely to impair driving ability? YES NO If Yes, explain:

Based on this examination, is the patient medically capable of:

▪ safely operating a motor vehicle? YES NO ▪ safely operating a commercial motor vehicle includes tractor trailers, passenger
▪ safely operating a motorcycle? YES NO buses, tank vehicles, school buses for 16 or more occupants (including the
driver), or vehicles carrying hazardous materials? YES NO
Based on this examination, patient needs the following: (check each appropriate item)
to be retested by DMV on Knowledge Road Both an adaptive device/equipment required to safely operate a motor vehicle.
a driver evaluation (with a certified independent driver rehabilitation specialist CDRS). a prosthetic/orthotic device to operate a motor vehicle
For clarification on any of the above, contact Medical Review Services at 804 367-6203.

Based on this examination, the patient's driving ability is likely to be impaired by limitations in the following areas: (check each appropriate item)
Judgment and Insight Sensorimotor Function
Problem Solving and Decision Making Cognitive Function Strength and Endurance Maneuvering Skills
Emotional or Behavioral Stability Reaction Time Range of Motion Use of Arm(s) and/or Leg(s)
ADDITIONAL RECOMMENDED RESTRICTIONS MEDICATIONS

PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER NAME (print) MEDICAL SPECIALTY

MEDICAL LICENSE NUMBER EXPIRATION DATE (mm/dd/yyyy) ISSUING STATE TELEPHONE NUMBER FAX NUMBER
( ) ( )
PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER SIGNATURE DATE (mm/dd/yyyy)

If you have questions or need more information to complete this page, call Medical Review Services (804) 367- 6203.

SECOND MEDICAL PROVIDER

Is the patient's condition(s) stable? YES NO If No, explain. Is the patient compliant with treatment? YES NO If No, explain:

Does the patient experience side effects of medications, which are likely to impair driving ability? YES NO If Yes, explain:

Based on this examination, is the patient medically capable of:

▪ safely operating a motor vehicle? YES NO ▪ safely operating a commercial motor vehicle includes tractor trailers, passenger
▪ safely operating a motorcycle? YES NO buses, tank vehicles, school buses for 16 or more occupants (including the
driver), or vehicles carrying hazardous materials? YES NO
Based on this examination, patient needs the following: (check each appropriate item)
to be retested by DMV on Knowledge Road Both an adaptive device/equipment required to safely operate a motor vehicle.
a driver evaluation (with a certified independent driver rehabilitation specialist CDRS). a prosthetic/orthotic device to operate a motor vehicle
For clarification on any of the above, contact Medical Review Services at 804 367-6203.

Based on this examination, the patient's driving ability is likely to be impaired by limitations in the following areas: (check each appropriate item)
Judgment and Insight Sensorimotor Function
Problem Solving and Decision Making Cognitive Function Strength and Endurance Maneuvering Skills
Emotional or Behavioral Stability Reaction Time Range of Motion Use of Arm(s) and/or Leg(s)
ADDITIONAL RECOMMENDED RESTRICTIONS MEDICATIONS

PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER NAME (print) MEDICAL SPECIALTY

MEDICAL LICENSE NUMBER EXPIRATION DATE (mm/dd/yyyy) ISSUING STATE TELEPHONE NUMBER FAX NUMBER
( ) ( )
PHYSICIAN/PHYSICIAN ASSISTANT/NURSE PRACTITIONER SIGNATURE DATE (mm/dd/yyyy)

If you have questions or need more information to complete this page, call Medical Review Services (804) 367- 6203.