Printable utah state functional ability evaluation medical report form 2010-2025

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The document is a Functional Ability Evaluation Medical Report required by the Utah Driver License Division. It collects personal information from applicants regarding their physical, mental, and emotional health that may affect their ability to drive. The report includes sections for healthcare professionals to assess and indicate the applicant's functional ability across various health categories, such as diabetes, cardiovascular conditions, neurological issues, and psychiatric conditions. It also outlines the process for disclosing health information and the implications of failing to provide necessary medical details.

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Click ‘Get Form’ to open the printable Utah State Functional Ability Evaluation Medical Report Form 2010 in the editor.
Begin by filling out the top portion of the form with your personal information, including your last name, first name, middle or maiden name, date of birth, and driver license number. Ensure you use black ink for clarity.
Provide your residential and mailing addresses. If there has been a change in either address, mark the box and print the new address clearly above.
In the health section, report any physical, mental, or emotional conditions that may affect your driving. Be thorough and include details about medications if applicable.
Sign and date the authorization section to allow healthcare professionals to disclose relevant health information regarding your ability to drive safely.
For the Health Care Professional Report section, ensure that a qualified healthcare professional completes their assessment accurately and signs it. This includes indicating any recommended restrictions.

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2015	4.9 Satisfied (36 Votes)
2014	4.4 Satisfied (321 Votes)
2014	4 Satisfied (20 Votes)
2010	4.3 Satisfied (44 Votes)
2009	4 Satisfied (30 Votes)
2008	4 Satisfied (29 Votes)

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What is a functional abilities evaluation?

A functional abilities evaluation (FAE) or functional capacity evaluation (FCE) is a comprehensive evaluation of your physical and functional abilities, using objective and measurable tests. The FAE can be general or specific to your job and related duties.

What does an FCE test consist of?

A FCE is a series of tests that help evaluate your physical abilities. The tests have you pull, push, lift and complete other tasks that relate to your job duties. Your physical therapist observes your performance as you complete these tests and records this data in a report.

What are the vision requirements for Utah drivers license?

What you need to do Valid out-of-state driver license. Proof of identity. Proof of social security number. Two (2) documents showing proof of Utah address. Additional documents for name change (if applicable) Get details about acceptable documents.

What is a functional ability evaluation medical report?

A functional capacity evaluation (FCE) is a set of tests that are used to identify a persons physical skills, functional capabilities, activity endurance, and work tolerances. The FCE is a 6-to-8-hour evaluation that is administered over two days by an occupational therapist or physical therapist.