Medical Condition Report 2

Medical Condition Report
Section 203 of the Highway Traffic Act requires that all legally qualified medical practitioners must report to the Registrar of Motor Vehicles the
name, address and clinical condition of any patient sixteen years of age or older who, "is suffering from a medical condition that may make it
dangerous for the person to operate a motor vehicle". To simplify the reporting process, the Ministry of Transportation has created this form.
Mail or fax to: Registrar of Motor Vehicles, Medical Review Section, Ministry of Transportation, 2680 Keele Street, Downsview, ON M3M 3E6. Tel.
No.: 416-235-1773 or 1-800-268-1481. Fax No.: 416-235-3400 or 1-800-304-7889.
Patient Information
Last Name First Name Middle Initial Fee Schedule Code
K035
Street No. and Name or Lot, Con. and Twp. Apt. No.
City, Town or Village Postal Code
Date of Birth Male Female Driver's Licence No. (if available)

Y M D
For your convenience, the following is a list of the more common medical conditions that are reported to MTO, to be
marked with an "X". If the condition you are reporting is not listed, please indicate it in the section marked "Other".
Alcohol Dependence Visual Field Impairment
Drug Dependence Diabetes or Hypoglycemia or other metabolic diseases-
Seizure(s)-Cerebral Uncontrolled
Seizure(s)-Alcohol related Mental or Emotional Illness-Unstable
Heart disease with Pre-syncope/Syncope/Arrhythmia Dementia or Alzheimer's
Blackout or Loss of consciousness or Awareness Sleep Apnea-Uncontrolled
Stroke/TIA or head injury with significant deficits Narcolepsy-Uncontrolled
Both Visual Acuity and Visual Field Impairment Motor Function/Ability Impaired
Visual Acuity Impairment Other (specify):
Optional
To expedite your patient's file, please provide further elaboration of clinical condition (if available) or attach as a separate report: Diagnosis; Other
Relevant Clinical Information (i.e current status - including results of investigations, medication(s), treatment and prognosis); and whether or not
the condition is a serious risk to road safety, threat to road safety is unknown or condition is temporary - weeks/months.
Y M D
Date of examination upon which this report is based: How long has this person been your patient?
Patient is aware of this report.
I wish to be notified if my patient requests a copy of this report, as releasing this report pursuant to a request
under the Freedom of Information Act may threaten the health or safety of the patient or another individual.
For MTO Use Only
030
Physician's Last Name, First Name and Middle Initial
Street No. and Name or Lot, Conc. and Township Apt. No.
City, Town or Village Postal Code Telephone. No.
Family Physician Emergency Room Physician Specialist Other

(Specialty)
Y M D
Doctor's Signature Date of Report
Requirement to Report Patients
Section 203 of the Highway Traffic Act states:
(1) Every legally qualified medical practitioner shall report to the Registrar the name, address and clinical condition of every
person sixteen years of age or over attending upon a medical practitioner for medical services, who, in the opinion of such
medical practitioner is suffering from a condition that may make it dangerous for such person to operate a motor vehicle.
(2) No action shall be brought against a qualified medical practitioner for complying with this section.
(3) The report referred to in subsection (1) is privileged for the information of the Registrar only and shall not be open for
public inspection, and such report is inadmissible in evidence for any purpose in any trial except to prove compliance with
subsection (1). R.S.O. 1980, c. 198, s. 203.
How to Complete the Form

You are required by law to provide the patient's name, address and the clinical condition, however, by including the patient's
sex and date of birth, we can accurately identify the individual. We suggest you keep a copy for your records. If you send by
fax, please do not mail the original. To expedite your patient's file, please provide further elaboration of clinical condition (if
available) or attach as a separate report: Diagnosis; Other Relevant Clinical Information (i.e current status - including results
of investigations, medication(s), treatment and prognosis); and whether or not the condition is a serious risk to road safety,
threat to road safety is unknown or condition is temporary - weeks/months.
What Conditions to Report

The Canadian Medical Association publishes the "Physician's Guide to Driver Examination" to assist physicians in
determining which conditions may make it dangerous to drive safely. The guide is available from the Canadian Medical
Association.
How the Ministry Determines Licence Status

The ministry considers the details of the individual's clinical condition reported by the attending physician, using guidelines
established by the Canadian Medical Association, and advice from the Ministry's Medical Advisory Committee, whose members
are experts in the fields of neurology, cardiology, psychiatry, endocrinology, ophthalmology, internal medicine, substance
abuse, geriatric medicine and physiatry.
The ministry relies on information provided on this form to help identify individuals who are at significant risk so that immediate
action to suspend the licence of any individual reported to have a chronic or deteriorating condition that is likely to impair
judgement or psychomotor skills or to be experiencing recurring or unexplained episodes of loss of consciousness.
If an individual is reported to have a clinical condition that is well controlled and the individual is under physician care, the
ministry generally does not suspend the licence. Where stability may be questionable, the ministry may request follow-up
medical information to confirm stability or request the individual undergo a driving examination or other appropriate
assessments.
Patient's Right to Access This Report

The Freedom of Information and Protection of Privacy Act requires the ministry to provide your patient with a copy of this report
if requested. It may be withheld only if there is evidence that its release would threaten the health or safety of yourself, the
patient or another individual. If you are concerned that the release of this report would threaten someone's health or safety,
make sure you notify the ministry by checking the appropriate box on the front of this form or by calling the ministry at (416)
235-1773 or 1-800-268-1481.

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Medical Condition Report

City, Town or Village Postal Code

Date of Birth Male Female Driver's Licence No. (if available)

Patient is aware of this report.

City, Town or Village Postal Code Telephone. No.

Family Physician Emergency Room Physician Specialist Other

How to Complete the Form

What Conditions to Report

How the Ministry Determines Licence Status

Patient's Right to Access This Report

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