DEPARTMENT OF PUBLIC SAFETY
LICENSING & RECORDS BRANCH
MEDICAL FITNESS REPORT
* Fee for examination is the responsibility of the licence applicant.
This form is to be completed by a licensed medical practitioner. A positive response must be elaborated upon at the bottom of the form. The
physician’s stamp must be affixed in the space provided.
Name of applicant Date of Birth
Licence Number Class of licence applied for
Does the patient have a history or diagnosis of any of the following:
Any loss or impairment of limbs or extremities or other structural defect, limitation of mobility
or co-ordination likely to interfere with the safe operation of a motor vehicle?
Any impairment of the musculo-skeletal or nervous system likely to interfere with the safe operation
of a motor vehicle?
Diabetes mellitus which requires either insulin or oral agents for control?
Myocardial infarction, angina pectoris, coronary insufficiency or thrombosis?
If first incidence, is the patient fully recovered?
Heart or lung disease including arrhythmia or respiratory dysfunction?
Hypertension accompanied by postural hypotension resulting in giddiness when
Requirement for hearing assistance?
Loss of consciousness or awareness due to a chronic or recurring condition?
Continuous use of any prescribed drug which could, in the dosage prescribed, impair ability to
operate a motor vehicle?
Clinical diagnosis of alcoholism or drug addiction?
Established medical evidence of a sustained psychiatric disorder with particular regard to
depression, suicidal tendencies or impulsive aggressive behaviour?
Any other physical or mental impairment, disease or condition which is likely to significantly
interfere with the individual’s ability to operate a motor vehicle safely?
This is to certify that I examined the abo