Illinois drivers must file this report when they have a medical or mental condition that may cause loss of consciousness or loss of ability to drive safely, or take medications that may impair driving. It is resubmitted at every license renewal. The driver completes Section I and signs a release, then a physician, nurse practitioner or physician assistant states whether the person is medically and mentally fit to drive and documents conditions, medications and recent episodes.
The driver completes Section I and signs the agreement and release. An MD, DO, NP or PA completes Sections II to V and signs with license details; any other provider treating the driver must give a fitness statement or a completed report of their own.
The driver prints their name, driver's license number, address, date of birth, gender and phone. By signing the release, the driver agrees to stay under the physician's care and follow treatment exactly as prescribed, authorizes the physician to release information to the Secretary of State and to report any change that would impair safe driving, and accepts that breaking these conditions can lead to denial or cancellation of driving privileges. The release states the report is valid for three months (90 days).
Enter the date Section II was completed. Question 1 is required: in your professional opinion, is the person medically and mentally fit to drive safely, yes or no. Question 2 requires a yes or no for every condition listed: cardiovascular (not for hypertension or hyperlipidemia alone), neurological, musculoskeletal, seizures, diabetes, dizzy or fainting spells, alcohol or drug abuse, developmental, mental and other conditions, naming the condition where the form asks.
List all current medications and dosages, including those prescribed by other physicians. If any medication is listed, a matching condition must be disclosed in question 2. Then answer whether any medication has side effects that would impair driving, with an explanation if yes, and whether the driver is compliant with medication and treatment, explaining a no. Check No medications prescribed if that applies.
State how long you have treated the driver and whether other providers are treating them. If yes, give each provider's name and contact information. The form notes that each other treating provider must supply a statement on medical and mental fitness to drive or a completed medical report of their own. Listing every treating provider here tells the Secretary of State whose input to expect.
Question 4 is required: mark the condition controlled, not controlled but will not affect driving, or not controlled and may affect driving. A not controlled answer needs details, which may include test results or lab values. Question 5 is required: in the past six months, has the driver's ability to drive safely been impaired for any reason, or has the driver had an attack of unconsciousness, with the date and details if yes. Question 6 asks for the date and details of the last such episode.
Use this space for anything the questions do not capture, such as recommended restrictions on the license or clinical context the Secretary of State should weigh. The patient's name is repeated at the top of the back page so the two sides stay matched.
Print the provider's name, address (printed or stamped), professional license number and issuing state, and phone; sign, date, check MD, DO, NP or PA and give the specialty. A second block lets another provider sign. Failure to provide license information returns the form to the driver, and signatures from chiropractors, podiatrists, residents, fellows, interns, RNs, LPNs or co-signers are not accepted. The form asks the provider to keep a copy.
Download the current version from the source each time; forms change without notice.
Medical Report For Conditions That May Impair Driving Safely
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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A physician (MD or DO), nurse practitioner or physician assistant completes the medical sections and signs Section V with license number and issuing state. The form does not accept signatures from chiropractors, podiatrists, residents, fellows, interns, RNs or LPNs, and co-signatures are not accepted. The driver completes Section I and signs the release.
Three months (90 days), as printed in the driver's release in Section I. The provider also records the date Section II was completed, so the exam, the completion date and the driver's submission to the Secretary of State should fall within that 90-day window.
When the driver has a medical or mental condition that may result in loss of consciousness or any loss of ability to drive safely, or takes medications that may impair driving. The driver must notify the Secretary of State within 10 days of becoming aware of the condition and resubmit the report at each renewal.
Yes. The Secretary of State investigates potential medical conditions reported by a licensed physician, law enforcement or the judicial system. These reporters do not need the driver's signature on documents submitted when they recommend the driver should not be driving.