The Colorado DR 2401 form serves as a Confidential Medical Examination Report required by the Colorado Department of Revenue's Division of Motor Vehicles. This form is utilized to assess a driver's fitness to operate a motor vehicle safely, based on a medical examination conducted by a licensed physician or physician assistant. It plays a crucial role in the evaluation process for obtaining or renewing a driver's license in Colorado.
The Colorado DR 2401 form serves as a vital document in assessing an individual's medical fitness to operate a motor vehicle. This form is designed for use by both patients and physicians, ensuring a comprehensive evaluation of the driver's health status. It includes sections for personal information, such as the patient's name, address, and date of birth, alongside a customer identification number. The form prompts patients to answer questions regarding their driving habits, including the frequency of trips, night driving, and any recent encounters with law enforcement or accidents. Physicians are tasked with providing a thorough medical examination and completing various sections that assess cardiovascular, neurological, musculoskeletal, and psychiatric conditions, among others. The physician must evaluate the patient's overall health and determine any necessary restrictions or recommendations for safe driving. This assessment not only guides the Department of Motor Vehicles in issuing or renewing driver licenses but also emphasizes the importance of public safety on the roads. The form is valid for 180 days from the date of examination, reinforcing the need for timely and accurate medical evaluations.
DR 2401 (09/14/20)
COLORADO DEPARTMENT OF REVENUE
Division of Motor Vehicles
P.O. Box 173350
Denver CO 80217-3350
FAX: (303) 205-8301
Confidential Medical Examination Report
Driver/Patient Section
Patient Last Name
First Name
Middle Initial
Street Address
City
State
ZIP
Customer Identification Number (CIN)
Date of Birth
Driver Statement of Understanding (Driver signature not required for DMV processing):
•My physician will conduct a medical examination to determine my fitness to operate a motor vehicle safely and responsibly.
•My physician will respond to any additional questions from the Department of Motor Vehicle (DMV).
•I understand that this form will be considered in any decision regarding the issuance of my driver license, pursuant to C.R.S. 42-2-111 & 42-2-112.
Signature of Driver or Patient
Date (MM/DD/YY)
Driver/Patient (respond to all questions below before seeing your physician)
1.How many driving trips do you make in a typical week?
2.Do any of your regular trips involve driving at night?
3.What is the one-way distance of your furthest regular trip
4.Do any of your regular trips involve speeds ≥ 55 MPH?
5.Were you pulled over by a police officer in the past year?
6.Were you involved in a crash as a driver in the past year?
Yes
No Miles
No
Physician Section
Instructions: use your best clinical judgment as you REVIEW AND COMPLETE ALL SECTIONS. Base severity ratings within each category on your overall assessment of impairment relative to the driving task. Form must be completed by the Physician (MD or DO) or Physician's Assistant (PA). Pursuant to C.R.S. 42-2-112, no civil or criminal action shall be brought against a physician or physician assistant licensed in Colorado for
providing a written medical opinion if the physician or physician assistant acts in good faith and without malice.
Examination Date (MM/DD/YY)
Does this patient have:
(Form is valid for 180 days from date of exam)
Cardiovascular Disease
Are you the primary care provider for this patient
Cardiac Arrhythmia
If yes, how many times have you seen this patient in the past year?
Heart Failure
If no, are you evaluating this patient for the first time today?
If no, have you reviewed the patient's medical records?
To your knowledge, is this patient:
Aware of his or her medical diagnosis & status?
Somewhat
AHA Functional Capacity (circle level if applicable)
Aware of functional impairments that may impact driving?
N/A I
II
III IV
Compliant with medications & basic requirements of self-care?
Need DMV Re-Examination in 1 year?
NO
Current Medications
To your knowledge, is this patient subject to any consistent medicine side effects or interactions that may impair driving ability?
Possibly
Not Likely
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Based on my observations of this patient and information relayed to me by this individual, I, reasonably and in good faith, believe that
_______________________________________________________________________is:
Patient Name
Recommended license restriction(s):
Must
Fit to operate a motor vehicle safely.
Fit to operate a motor vehicle safely contingent upon passing a DMV Road Test.
Daylight Driving Only
Choose
NOT FIT to operate a motor vehicle safely and responsibly due to significant
No Highway/Freeway Driving
One
medical-functional compromise or deficit.
Hand Control
{Fitness to drive determination pending; rehab permit required
Mile Radius Only ________
Restricted MPH _________
Patient also requires an eye exam
Steering Device
Specialty (Required)
License Number (Required)
Phone Number (Required)
Specialty Cushion
Foot Device
Automatic Transmission Only
Other_________________________
Cognitive, Cerebrovascular or Neurological
Condition is:
Stable
Progressive
N/A
Mental Status__________________________________________________________________________________________ (list test and score)
Confusion or Disorientation
Memory Loss or Forgetfulness
Inattention or Distractibility
Impaired Judgment
Visual-Spatial Deficit
Slowed Processing Speed
Cognitive Impairment
Cerebrovascular Disease
Neurological Condition
Alzheimer's Disease
Cerebral Infarction or Stroke
Brain Injury (open or closed)
Vascular Dementia
Hemorrhage or Aneurysm
Tumor or Malformation
Frontotemporal or Pick's
Transient Ischemic Attack
Parkinson's Disease
Dementia (other or unknown)
Carotid Occlusion or Hypoxia
Multiple Sclerosis
Combined Impairment for Driving
Unimpaired
Very Mild
Mild
Moderate
Severe
(Likely fit to Drive)
(Questionable Fitness)
(Likely Unfit to Drive)
(Unfit to Drive)
Check (X) Highest Level for Section
Consciousness, Metabolic or Respiratory
*Date of last event with impaired consciousness (MM/DD/YYYY): _____________________________________________
Disorder of Consciousness or Alertness*
Blackout or Syncope*
Sleep Apnea or Narcolepsy
Medication Effect
Chronic Sleep Deprivation
Epilepsy or Seizure Disorder
Dizziness or Postural Hypotension
Metabolic Condition
Respiratory Condition
Diabetes (Type 1 or 2)
Asthma or shortness of Breath
Thyroid Condition (Hypo or Hyper)
COPD
Morbid Obesity or Fluid retention
Oxygen Dependent
Musculoskeletal, Movement or Neuromuscular
Check All That Apply:
Arthritis (Osteo or Rheumatoid)
Frailty or General Weakness
Motor Neuron Disease
Muscular Dystrophy
Uses Cane or Walker
Paralysis - Arm
Wheelchair Dependent
Paralysis - Leg
Restricted or Weakness - Arm
Loss of Limb
Difficulty Transferring
Prosthesis or Brace - Arm
Restricted or Weakness - Leg
History of Falls
Problems with Balance
Prosthesis or Brace - Leg
Restricted Neck Range of Motion
Other_____________________
Orthopedic or Movement
Psychiatric, Emotional or Addiction
Depression
Bipolar Mood Disorder
Psychosis or Schizophrenia
Alcohol Abuse or Addiction
Drug Abuse or Addition
Suicidal or Homicidal
Anxiety or Post-Traumatic Stress
Chronic Pain (causing distress)
Other ______________________________
Physician Name (Printed)
Signature (Required)
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