555 Wright Way
Carson City, NV 89711
Reno/Sparks/Carson City (775) 684-4DMV (4368)
Las Vegas Area (702) 486-4DMV (4368)
Rural Nevada or Outside Nevada (877) 368-7828
Fax: (775) 684-4829
CONFIDENTIAL PHYSICIAN’S REPORT
PLEASE NOTE: According to the Nevada Administrative Code, the Department of Motor Vehicles MUST receive
this report within 30 DAYS after the date of the examination.
Driver’s License No.
Date of Birth (MM/DD/YYYY)
In your opinion, will this medical condition affect the patient’s ability to drive a vehicle safely?
*If Yes or Uncertain, please explain:
Status of Patient’s Medical Condition(s)*:
Worsening or Deteriorating
Subject to Change
*If multiple conditions exist, please describe status and prognosis.
How long has this person been your patient?
Years Months Date of Last Examination:
Is your patient under a controlled medical program?
*If Yes, how long has control been maintained? Years Months
Is the patient adhering to the medical regimen?
*If No, please explain:
Is the patient knowledgeable about the medical condition?
Medications prescribed (please list type and dosage):
Will these medications affect the patient’s ability to operate a motor vehicle safely?
No *If Yes, please explain:
DLD-7 (Revised 9/2006)
Please complete BOTH SIDES of this form.
Does the nature of the condition indicate loss/lapse of consciousness, seizure activity, fainting or dizzy
*If Yes, please indicate the date (MM/DD