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Click ‘Get Form’ to open the pa dl 104 in the editor.
Begin by filling out the Patient Information section. Enter the Driver’s License Number, Height, Sex, Last Name, First Name, Date of Birth, Eye Color, Telephone Number, and Email Address if applicable.
Complete the Street Address field accurately. Remember that a P.O. Box can be included but cannot be the only address provided.
In the Driver Qualification Section, answer questions regarding the patient's treatment duration and any mental or emotional disorders diagnosed.
Address each impairment question carefully. Provide detailed responses about attentiveness, intellectual functioning, perception, reaction time, coordination, muscular strength, and personality factors.
If applicable, indicate whether the patient is on medication and specify its type and dosage. Assess if it affects their driving safety.
Finally, fill in the Health Care Provider Information section with your details and sign at the bottom to confirm accuracy.

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