The Colorado DR 2401 form is a Confidential Medical Examination Report designed to assess a driver's fitness to operate a motor vehicle. This form is essential for ensuring that individuals meet the necessary health standards to drive safely. It requires input from both the driver and a licensed physician, providing a comprehensive evaluation of any medical conditions that may impact driving abilities.
The Colorado DR 2401 form serves a crucial role in ensuring that individuals are medically fit to operate a motor vehicle safely. This form is designed to be completed by a physician or physician's assistant and is essential for assessing a driver’s health in relation to their ability to drive. It includes sections for both the driver and the physician, where critical information is gathered. Drivers must answer questions regarding their driving habits, such as the frequency of trips and any incidents involving law enforcement or accidents. Physicians, on the other hand, evaluate various health conditions that could impact driving, including cardiovascular, neurological, and psychiatric disorders. The form also allows for the recommendation of specific license restrictions based on the patient's medical condition. This comprehensive assessment not only aims to protect the driver but also enhances the safety of all road users. Importantly, the form is valid for 180 days from the examination date, ensuring that the information remains current and relevant.
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
Page 1 of 2
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)
Page 2 of 2
The Colorado DR 2401 form is a Confidential Medical Examination Report required for individuals seeking to determine their fitness to operate a motor vehicle safely. In addition to this form, several other documents may be necessary during the application or re-examination process. Below is a list of these forms and documents, along with brief descriptions of their purposes.
These forms and documents play a crucial role in ensuring that drivers are fit to operate vehicles safely. Completing the necessary paperwork helps the Department of Motor Vehicles make informed decisions regarding driver licensing and public safety.
Dmv Forms Colorado - Filling out this form accurately is critical for successful record access.
Colorado Title Complete Notice - It is essential to include clear details about the accident on the form.
Colorado Dmv Forms - This form applies to vehicles established by a surety bond.
Filling out the Colorado DR 2401 form is a straightforward process. This form requires information from both the patient and their physician. After completing the form, it will be submitted to the Department of Motor Vehicles (DMV) for review. Follow these steps to ensure everything is filled out correctly.
The Colorado DR 2401 form is similar to the Medical Examination Report (MER) required by the Federal Motor Carrier Safety Administration (FMCSA). Both documents serve the purpose of assessing an individual's medical fitness to operate a vehicle. The MER requires a certified medical examiner to evaluate the driver's health, focusing on conditions that could impair their ability to drive safely. Just like the DR 2401, the MER includes a series of questions about the driver's medical history and current health status, ensuring that the examiner has a comprehensive understanding of the individual's fitness to drive.
Another document comparable to the Colorado DR 2401 is the DOT Medical Card, which is also used in the context of commercial driving. This card is issued after a medical examination and confirms that the driver meets the necessary health standards to operate a commercial vehicle. Similar to the DR 2401, it requires a medical professional to evaluate various health factors, including vision, hearing, and any medical conditions that may affect driving. Both documents aim to ensure public safety by confirming that drivers are physically capable of handling their vehicles responsibly.
The Driver’s License Medical Evaluation form used in various states shares similarities with the Colorado DR 2401. This form is often required when a driver has a medical condition that may affect their driving ability. Like the DR 2401, it includes sections for both the driver and the physician to provide information about the driver’s health status. The goal is to assess whether any medical issues could impair driving, ensuring that only those fit to drive are allowed to hold a license.
Additionally, the Vision Evaluation Report is another document that aligns with the DR 2401. This report specifically focuses on a driver’s visual acuity and overall vision health, which are critical for safe driving. While the DR 2401 covers a broader range of health issues, both documents require a professional assessment and are utilized by the Department of Motor Vehicles to determine a driver's fitness. A clear understanding of a driver’s vision capabilities is essential for evaluating their overall ability to operate a vehicle safely.
The Functional Capacity Evaluation (FCE) is also similar to the Colorado DR 2401 in its focus on assessing an individual's physical capabilities. An FCE is typically conducted to determine a person's ability to perform work-related tasks, but it can also be applied to driving assessments. Both the FCE and the DR 2401 require a thorough evaluation of physical limitations and capabilities. This ensures that individuals with specific impairments are identified and appropriate restrictions or recommendations are made regarding their driving abilities.
The Medical Fitness for Duty Evaluation is another document that parallels the Colorado DR 2401. This evaluation is often used in occupational settings to determine if an employee can safely perform their job duties, including driving. Similar to the DR 2401, it assesses various health factors and may include input from multiple healthcare professionals. The goal is to ensure that individuals are fit for their roles, thereby protecting both the individual and the public.
The State-Specific Driver Evaluation form, used in various states, also bears similarities to the Colorado DR 2401. This form is often required when a driver has experienced medical issues that could affect their driving. Like the DR 2401, it collects detailed information about the driver’s medical history and requires a physician's assessment. The purpose of both forms is to evaluate the driver’s fitness and to ensure that they can operate a vehicle safely.
Finally, the Patient Health Questionnaire (PHQ) can be seen as related to the Colorado DR 2401. While primarily used to assess mental health conditions, the PHQ can provide valuable insights into a patient’s emotional and psychological well-being, which can affect driving ability. Both documents require a thorough understanding of the individual’s health status, and they emphasize the importance of mental fitness in relation to safe driving practices.
The Colorado DR 2401 form is a Confidential Medical Examination Report. It is used to assess a driver's fitness to operate a motor vehicle safely. The form requires input from both the driver and a qualified medical professional, such as a physician or physician's assistant. The information collected helps the Department of Motor Vehicles (DMV) make informed decisions regarding driver license issuance.
The form must be completed by the driver or patient and a licensed medical professional. The driver provides personal information and answers questions about their driving habits and health status. The physician or physician's assistant evaluates the driver’s medical condition and determines their fitness to drive.
The DR 2401 form is valid for 180 days from the date of the medical examination. After this period, a new examination and form submission will be necessary to assess the driver’s current fitness level.
If the physician concludes that the driver is unfit to operate a vehicle safely, they will indicate this on the form. The driver may face restrictions or may need to undergo further evaluations or rehabilitation. The DMV will consider this recommendation when making decisions about the driver's license status.
When filling out the Colorado DR 2401 form, it is important to follow certain guidelines to ensure accuracy and completeness. Here are nine things to keep in mind: