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It explains how personal information is collected and used for determining driving capability and enabling medical practitioners to bill the Medical Services Plan via Teleplan. The form provides sections for driver history, vision screening and physical findings, medical opinion on driving impact, condition details, recommendations, physician certification, and consent to release information, including examinations, signatures, and submission instructions.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/roadsafetybc-drivers-medical-examination-instructions-and-form-sections/448486/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/roadsafetybc-drivers-medical-examination-instructions-and-form-sections/448486.png","ImageObject",300,407,{"name":92,"@type":93},"Taylor Morgan","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-04","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":19},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What is the purpose of the RoadSafetyBC Driver’s Medical Examination form?","Question",{"text":112,"@type":113},"The form gathers medical and related information to determine whether a driving-related condition may affect fitness to drive. It also supports billing through the Medical Services Plan via the Teleplan system.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How is personal information collected and used?",{"text":117,"@type":113},"Personal information on the form is collected under the authority of the Freedom of Information and Protection of Privacy Act and the Motor Vehicle Act. It is used to assess driving fitness and allow a medical practitioner to bill for the service.",{"name":119,"@type":110,"acceptedAnswer":120},"What does the physician or NP need to provide in the certification section?",{"text":121,"@type":113},"The physician or NP certifies the information provided is true and complete to the best of their knowledge. 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If you have any questions about the collection of your personal information please see the contact information in the “To the driver” section of the Instructions.  \n1  \nAREA ABOVE FOR OFFICE USE  \nDRIVER AND PHYSICIAN OR NURSE PRACTITIONER-SEE BACK FOR INSTRUCTIONS  \n REASON FOR EXAMINATION AND CLASS  \nThis report should focus on the condition(s)  \nstated above.  \n• For sections A and B, provide full information on the area(s) that, in your opinion, apply to the condition(s) being monitored and use section D as needed.  \n• Section C must be completed.  \n\n| A. HISTORY (Reference to the 2010 BC Guide to Drive in Determining Fitness to Drive: Web links are provided on the back of form) |  |  |  |\n| --- | --- | --- | --- |\n| VISION (section 2 of Physician’s Guide)\u003Cbr> Acuity loss\u003Cbr> Field defect\u003Cbr> Eye disease\u003Cbr> Other   | CARDIOVASCULAR (sections 4 and 6)\u003Cbr> Syncope Date   Cause  \u003Cbr> CAD (M . I. , angioplasty, CABG) Date  NYHA Functional Class  \u003Cbr> Arrhythmia\u003Cbr> Pacemaker\u003Cbr> ICD  Primary  Secondary Date  \u003Cbr> Congestive heart failure: LVEF  \u003Cbr> Aneurysm Site   Size  \u003Cbr> Peripheral Vascular disease\u003Cbr> Other   | CNS (sections 5 and 7)\u003Cbr> CVA/TIA Date  \u003Cbr> Seizure disorder  Provoked  Epilepsy Date of last seizure  \u003Cbr> Narcolepsy\u003Cbr> Congenital condition (Cerebral palsy, etc.)\u003Cbr> Progressive deficit (Parkinson’s, MS, ALS, etc.)\u003Cbr> Stable deficit (Paraplegia, Nerve damage, etc.)\u003Cbr> Cognitive impairment MOCA   MMSE  \u003Cbr> Dementia Diagnosis   GDS  \u003Cbr> Significant head injury\u003Cbr> Other   | RESPIRATORY (section 8)\u003Cbr> Oxygen required when driving\u003Cbr> Obstructive sleep apnea  Mild  Mod to Severe\u003Cbr> CPAP compliant  \u003Cbr> Apnea Hypopnea Index (AHI)  \u003Cbr> Epworth Score   |\n| HEARING (section 3)\u003Cbr> Hearing loss\u003Cbr> Vertigo  with warnings  without warnings\u003Cbr> Date of last vertigo episode  \u003Cbr> Other   |  |  |  |\n|  |  |  | ENDOCRINE (section 9)\u003Cbr> Diabetes Insulin  Yes  No\u003Cbr> Severe hypoglycemia Date  \u003Cbr> Hypoglycemia unawareness Date  \u003Cbr> Stable BG Control  Compliant w/ Treatment HbA1 C   Date  \u003Cbr> Other  \u003Cbr>OTHER CONDITIONS\u003Cbr> General debility or functional decline\u003Cbr> Other (see guide)   |\n| MUSCULOSKELETAL (section 11)\u003Cbr> Amputation\u003Cbr>Limb affected   Date  \u003Cbr> With Prosthesis  Without Prosthesis\u003Cbr> Adaptive Device    None\u003Cbr> Weakness\u003Cbr> Range of motion loss\u003Cbr> Other   | PSYCHIATRIC (section 12)\u003Cbr> Psychosis\u003Cbr> Severe depression\u003Cbr> Impaired judgment, insight\u003Cbr> Medication non-compliance\u003Cbr> Stable Psych condition\u003Cbr> Other   | DRUGS AND ALCOHOL (sections 13 and 14)\u003Cbr> Alcohol or drug abuse in past 2 years\u003Cbr> Alcohol related seizure\u003Cbr> Addiction rehab taken   refused  \u003Cbr> Prescribed drugs that could impair\u003Cbr> Psychoactive drugs\u003Cbr> Narcotics\u003Cbr> Other   |  |\n| B. VISION SCREENING AND PHYSICAL FINDINGS AFFECTING DRIVING May include EVF/VFT done within one year if available. |  |  |  |\n\nC. OPINION Having completed A & B as applicable, in your opinion, does patient have a condition that may affect driving:  \nNO  \nYES  \nMay in future-recommend follow-up in   years  \nD. DETAILS OF CONDITION(S) THAT AFFECT OR MAY AFFECT DRIVING May include relevant specialists’ reports or lab results.  \n\n| E. RECOMMENDATION(S) |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- |\n|  Specialist Consult -Type   Enclosed:  Yes  No I will arrange:  Yes  No |  |  | | Road test to assess   Restrictions (Reason & Type)  \u003Cbr>|  |\n| F. DRIVER’S CERTIFICATION AND CONSENT TO\u003Cbr>RELEASE INFORMATION |  |  | G. RELATIONSHIP WITH PATIENT |  |  |\n| 1. I certify that the i","cbCaiaX5K0dCOQyc","https://ap.wps.com/l/cbCaiaX5K0dCOQyc","pdf",1396843,"English","# Instructions\n# A. History\n## Vision\n## Cardiovascular\n## CNS\n## Respiratory\n## Hearing\n## Endocrine\n## Musculoskeletal\n## Psychiatric\n## Drugs and Alcohol\n# B. Vision screening and physical findings affecting driving\n# C. Opinion\n# D. Details of condition(s) that affect or may affect driving\n# E. Recommendation(s)\n# F. Driver’s certification and consent to release information\n# G. Relationship with patient","[{\"question\":\"What is the purpose of the RoadSafetyBC Driver’s Medical Examination form?\",\"answer\":\"The form gathers medical and related information to determine whether a driving-related condition may affect fitness to drive. It also supports billing through the Medical Services Plan via the Teleplan system.\"},{\"question\":\"How is personal information collected and used?\",\"answer\":\"Personal information on the form is collected under the authority of the Freedom of Information and Protection of Privacy Act and the Motor Vehicle Act. It is used to assess driving fitness and allow a medical practitioner to bill for the service.\"},{\"question\":\"What does the physician or NP need to provide in the certification section?\",\"answer\":\"The physician or NP certifies the information provided is true and complete to the best of their knowledge. The driver also consents to the release of the medical report and relevant past or future reports to the Superintendent of Motor Vehicles.\"}]","RoadSafetyBC Driver’s Medical Examination - Instructions and Form Sections | PDF",1790727325]