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Fillable Printable Driving Licence Medical Report Form

Fillable Printable Driving Licence Medical Report Form

Driving Licence Medical Report Form

Driving Licence Medical Report Form

To drive you must meet certain medical fitness standards. For this purpose vehicles are classed as Group 1 and Group 2.
If you are applying for a vehicle in both Groups (See note 2 overleaf) please tick Group 1 and 2 on this form. Where an applicant
meets the medical criteria for Group 2 vehicles, they will automatically meet the medical criteria for Group 1 vehicles.
Driver number
First name(s)
Surname
Address 1
Address 2
Town/City
County
Postcode
Date of birth
Day Month Year
PPSN
(Please X the appropriate box)
I wish to undergo a medical examination on foot of my application for a learner permit/driving licence as required
by the Road Traffic Acts. (See note 1 overleaf).
My application is for a driving licence/learner permit as a driver of a Group 1
or Group 2 vehicle.
(See note 2 overleaf).
If you have in the past suffered or currently suffer from epilepsy,
please indicate the date of your last seizure.
Day Month Year
Signature
(To be signed in the presence of your Medical Practitioner)
Day Month Year
This form must be submitted to National Driver Licence Service with an application for a driving licence/learner permit
within one month of its completion by a Medical Practitioner.
VEHICLES IN GROUP 1 AND GROUP 2
Driving Licence Medical Report Form
To be completed by a Medical Practitioner whose name is on the General Register of Medical Practitioners in Ireland.
I, the undersigned registered medical practitioner report that:
The applicant has signed the declaration in my presence
I have examined the applicant by reference to the medical fitness standards required by the Road Trafc Acts and in my
opinion, the applicant. (Please X the appropriate box(es) below):
Meets the prescribed medical fitness standard set out for vehicles in Group 1 only. Yes
No
Meets the prescribed medical fitness standard set out for vehicles in Group 1 and Group 2.
(This should only be completed if the applicant has applied for or holds a Group 2 licence/permit.) Yes No
(See notes 3 and 4 overleaf).
Is fit to drive for a period of:
Group 1 Vehicles and Licence Category
1 year 3 years 10 years
Group 2 Vehicles and Licence Category
1 year 3 years 5 years
(See note 3 below with maximum duration of a licence for Group 2 drivers).
The applicant has a physical disability requiring adaptations be made to a vehicle
to meet the requirements of their disability. Yes No
The applicant has had a limb prosthesis/orthesis. Yes No
The applicant needs to wear corrective lenses while driving. Yes No
The applicant is medically unfit to drive. Yes No
My opinion as to (INSERT APPLICANTS NAME IN BLOCK CAPITALS) __________________________________________________
medical fitness is that he/she is fit to drive vehicles of the Group indicated from any date up to four calendar months
from todays date.
Signature
Day Month Year
Stamp of Medical Practitioner whose name is on the
General Register of Medical Practitioners in Ireland
Medical Practitioner Telephone Number
EXPLANATORY NOTES
1. To complete your medical examination you must go to your doctor, have your medical examination and sign this form in the presence of
the doctor. When the form is completed by your doctor you must send it to National Driver Licence Service with your learner permit/driving
licence application within one month of the date of the medical examination.
2. For medical fitness standards vehicles are classed as being in Group 1 or Group 2. The graphic overleaf describes which vehicles are in Group
1 and in Group 2. Further information on each licence category can be found on the licence application form. A higher standard of medical
tness is required of those drivers who hold licences for Group 2 vehicles. Please note that Group standards apply to all categories of
vehicles within that Group. Individual categories should not be marked on the table overleaf.
3. A person driving a Group 2 category vehicle must be certifi ed as medically fit every five years.
4. Applicants over 70 years of age can only be certified as being fi t to drive for either one or three years.
Driving Licence Medical Report Form
Date of Examination:
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