555 Wright Way
Carson City, NV 89711
Reno/Carson City (775) 684-4DMV (4368)
Las Vegas (702) 486-4DMV (4368)
Fax: (775) 684-
4829
dmv.nv.gov
DLD-7 (1/2023) Page 1 of 2
CONFIDENTIAL PHYSICIANS REPORT
PLEASE NOTE:
According to the Nevada Administrative Code, the Department of Motor Vehicles MUST receive this
report within 30 DAYS after the date of the examination.
All fields are MANDATORY
Driver’s License No:
Date of Birth (MM/DD/YYYY)
Phone Number:
Patient’s Name:
Last
First
Middle
1. Diagnosis:
2. In your opinion, will this medical condition affect the patient’s ability to drive a vehicle safely?
Yes*
No
Uncertain*
*If Yes or Uncertain, please explain:
3. Status of Patient’s Medical Condition(s)*:
Improving
Stable
Worsening or Deteriorating
Subject to Change
*if multiple conditions exist, please describe status and prognosis.
4. How long has this person been your patient?
Years
Months
Date of Last Examination:
5. Is your patient under a controlled medical program?
Yes*
No
*if Yes, how long has control been maintained?
Years
Months
6. Is the patient adhering to the medical regimen?
Yes
No*
*if No, please explain:
Yes
No
7. Is the patient knowledgeable about the medical condition?
8. Medications prescribed (please list type and dosage):
9. Will these medications affect the patient’s ability to operate a motor vehicle safely?
Yes*
No
*if Yes, please explain:
You must present this form in person to the DMV if you wish to have one of these medical conditions imprinted on your driver’s license
or identification with the medical indicator symbol on the front. There is no charge to have this added to your card, however, there will
be a $3.25 fee to produce a new card.
DLD-7 (11/2023) Page 2 of 2
10. Does the nature of the condition indicate loss/lapse of consciousness, seizure activity, fainting or
dizzy spells? Yes* No
*if Yes, please indicate the date (mm/dd/yyyy) of the last occurrence:
Yes
No
10a. Was the seizure or loss of consciousness and isolated incident?
10b. Are additional seizures likely t
o occur?
Yes
No
11. Please recommend any restrictions you feel are necessary for this patient to safely drive a vehicle:
12. Physician’s Comments:
Date of Examination
Signature of Authorized Physician, APRN or PA
License Number
Physician Office Phone Number, APRN or PA
Print Name of Physician, APRN or PA
Office Address of Physician, APRN or PA
City
State and Zip Code
I hereby authorize any physician, surgeon, advanced practical registered nurse, physician’s assistant, or
other person, and/or any clinic, or hospital, including the Department of Veterans Affairs or government
hospital, to release any and all
acquired medical information that specifically addresses the information on
this form and may relate to, or affect my ability to operate a motor vehicle safely.
Patient’s Signature
Date
OPTIONAL: To have a medical indicator on your license or identification card to alert police and medical
personnel, your physician must state on this form that you suffer from one of the medical conditions listed
below. Check only one.
The medical indicator includes a blue medical symbol on the front and one medical code printed
on the back of your driver’s license or identification card.
Code
Description
Code
Description
E934.2
Anticoagulants (adverse effect)
389.9
Diminished Hearing
299
Autistic Disorder
345.9
Epilepsy
369.00
Blindness and Low Vision
995.6
Food Allergies
496
Chronic Obstruction Pulmonary
Disease
286.52
Hemophilia
414.01
Coronary Atherosclerosis
995.86
Malignant Hyperthermia
389.10
Deafness
310.9
Mental Illness
311
Depression
295.5
Schizophrenia
250.9
Diabetes
282.6
Sickle-Cell
719.7
Difficulty in Walking
710.0
Systemic Lupus
Erythematosus
