DOT-H2058 (05/2018)
MEDICAL REPORT
(Applicant’s Full Name)
NOTICE TO APPLICANT:
Please take this form to a licensed medical doctor or any other competent authority
acceptable to the Examiner of Drivers. You are responsible for any expense involved. The
Medical Advisory Board will review your medical report that will be identified by number only. The
board will provide an opinion regarding your fitness to drive safely based on the guidance in the
National Highway Safety Traffic Administration publication entitled, Medical Conditions and
Driving, September 2005.
The County's Examiner of Drivers will review the board's opinion and decide
whether you meet the standards required to operate a motor vehicle in the State of Hawaii.
NOTICE TO MEDICAL EXAMINER:
This applicant is required to undergo a medical examination to provide the driver licensing
administrator information to decide whether the physical and mental standards to be licensed in this State
are met. Your report will be reviewed by this agency and the Medical Advisory Board before the applicant
is licensed. State laws make the licensing administrator responsible for the licensing action and your
medical report is strictly advisory. Please be assured that your report will be used to grant driving
privileges commensurate with driving ability while considering driving need and public safety.
Please complete the form for the medical condition in question so that we may be properly
informed about the medical conditions that might impair safe driving ability. If your examination
reveals other conditions that in your professional opinion might compromise the applicant’s ability to
drive safely, please provide the information. Consult with other medical authorities, if necessary.
The applicant is responsible for any professional fee for this examination. The
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION form is for your protection; it
should be signed by the applicant and kept in your files.
Thank you for your assistance in this program.
………………………………………………………………………………………………………..........................................................
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
I hereby authorize the release of my medical history to the county examiner of drivers for deciding my
eligibility for a driver's license by __________________________________________________________
(Name of licensed medical doctor or any other competent authority acceptable to the Examiner of Drivers)
_______________________________________________________________
Signature of applicant Date
NOTICE TO APPLICANT:
You are given this Medical Evaluation Report (DOT-H 2058) to be completed and signed by a doctor (licensed to do
physical examinations). The completed report must be submitted to our office within thirty (30) calendar days for review and
may be forwarded to the State of Hawai‘i Medical Advisory Board (MAB) for further review and recommendation. Failure to
meet the requirement may result in the cancellation of your driver’s license (Hawai‘i Administrative Rule 19-122-354 & 355
effective 5/2/08).
____________________________________________________ ____________________________________
Signature of Applicant Date:
DOT-H2058 (05/2018)
DOT-H2058 05/2018
Hawaii Department of Transportation
MEDICAL REPORT
Please be advised that the decision to allow an applicant to
continue to retain his/her Hawaii driver’s license is
contingent upon the information provided in this medical
report. It is in the best interest of the applicant and the
public, that all questions be answered completely. This
report will be reviewed by a panel of physicians who may
request additional medical information.
This form will become part of the applicant’s record, is for
confidential use of the physician, county DMVs, and the
Hawaii Department of Transportation only.
Thank you for your assistance.
ALL INFORMATION MUST BE TYPED OR CLEARLY PRINTED
DMV Use Only
Case #
OAHU
HAWAII
MAUI
KAUAI
Reason for Medical Report:
Applicant Information
Applicant’s Name (Last, First, Middle Initial)
Age
Driver’s License #
Telephone #
Sex
(Circle One)
M F
Physician’s Report
How long have you treated this patient?
Date of last examination:
A. Has the patient had loss of consciousness or alteration in awareness?
Yes □
No □
1. □ Syncope
□ Seizures
□ Hypoglycemia
□ Other:
2. Frequency of events?
3. Date of last event?
4. Patient’s condition is:
□ Unstable
□ Stable
□ Unknown
5. Inciting/Modifying factors? □ Unknown
6. Describe any assistive device, (e.g. pacemaker, automatic implanted cardioverter, continuous glucose
monitoring system, etc.) and give implant date.
DOT-H2058 (05/2018)
B. Does patient have physical impairments that affect safe driving?
Yes □
No □
1. □ Amputation
□ Frozen joint(s)
□ Decreased mobility
□ Weakness/ Hemiparesis/ Paraplegia □ Paralysis
For Hemiparesis: (circle one) Left / Right
□ Parkinsonism
□ Other: ______________________________________________________
(For Visual or Hearing issues please see Sections E and F below)
2. How does it affect driving ability?
3. Patient’s condition is:
□ Unstable
□ Stable
□ Unknown
4. Modifying factors? Assistive devices?
5. How long has patient had impairment?
6. Has vehicle been modified to accommodate limitations?
7. How long has patient been using modification?
C. Does patient have cognitive or psychological impairments that
affect safe driving?
Yes
□
No
□
1. □ Dementia/Memory Impairment
□ Severe Psychiatric Illness
□ Danger to Self or Others
□ Other: __________________________________________________
(For Alcohol or Substance Abuse, See section D Below)
2. How does it affect driving ability?
3.Patient’s condition is:
□ Unstable
□ Stable
□ Unknown
4. Modifying factors? Treatment?
D. Does patient have a history of alcohol or substance abuse?
Yes □
No □
1. What substances have been abused within the last five years or are currently being abused?
2. Is your patient being treated for alcohol or substance abuse? (Medications, Psychiatry, AA, Other?)
Yes □
No □
3. Is your patient currently clean and sober? Yes
□
No
□
If yes, for how long?
DOT-H2058 (05/2018)
E. Does patient have a vision problem that may affect safe driving?
Yes □
No □
1. Does the patient have any medical conditions that affect their vision (acuity or visual fields)? If yes, list
condition(s) and provide the distance visual acuities and amount of visual fields for each eye.
Uncorrected
Corrected
Degrees
Right Eye
20/
20/
Left Eye
20/
20/
2. Is the patient receiving any treatment that will modify their visual capability?
Yes □ No □
If yes, list condition(s) and provide the amount of visual fields in each eye.
F. Does patient have a hearing problem that may affect safe driving?
Yes □ No □
1. Is this corrected with hearing aid? Yes □ No □
2. Patient’s condition is:
□ Unstable
□ Stable
□ Unknown
Physician’s Report
What medication(s) is the patient taking? How often? (please name drugs and attach additional page if
needed) □ Medication Record Provided as Attachment
DRUG DOSE SCHEDULE
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
G. Summary
1. In your opinion is this person capable of safe driving?
□
Other (Please explain):
Yes □
No □
2. Do you recommend a road test? Yes □ No □
3. Do you recommend the maximum licensing period? Yes □ (see below for the max. periods by age)
□ No, recommend a reduced validity period of ________ Year(s)
Maximum Validity Period
Age 16-17
Age 18-24
Age 25-71
Age 72+
1 to 4 years
4 years
8 years
2 years
I certify that I am a licensed medical provider and have determined this applicant’s physical and
mental ability to operate a motor vehicle. I understand that my recommendations will be used by a county
Driver Licensing Administrator to determine the eligibility of the applicant to be licensed in the State of
Hawaii.
Medical Examiner’s Name (print clearly)
Date of Examination
Office Telephone #
Signature of licensed medical examiner
Medical License #
Specialty
