WisDOT Medical Review sends this four-page report when it needs a clinician's opinion on whether a person is medically safe to drive. The reason for the request determines which sections apply: general medical, mental or emotional, neurological, endocrine, cardiovascular or pulmonary. Section G asks whether the person is safe to drive a car, commercial vehicle or bus, and what restrictions or re-examination to require.
WisDOT fills in the applicant details and the reason it is requesting information. An MD, DO, PA-C or APNP completes Sections A and G for every applicant plus the condition-specific sections, and signs with specialty and license number.
Download the current version from the source each time; forms change without notice.
Medical Examination Report
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.
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Sections A and G are for every applicant. Add Section B for mental or emotional conditions, C for neurological, D for endocrine conditions such as diabetes or kidney disease, E for cardiovascular and F for pulmonary. The first page notes why DMV is requesting information and whether a Driver Condition or Behavior Report is attached.
The report must be based on an exam within the past 90 days, unless DMV writes a more recent exam-date-since in Section G. All information about the provider and the exam date must be complete for WisDOT to accept the report.
Section G lists continuous oxygen use, daylight driving only, no freeway or interstate, roads posted at a chosen speed between 25 and 55 mph, a stated radius from home and other enforceable restrictions. The clinician may also recommend a full or skills-only re-examination of driving ability or additional medical evaluation.