Printable utah state functional ability evaluation medical report form 2010-2026

1. Click ‘Get Form’ to open the printable Utah State Functional Ability Evaluation Medical Report Form 2010 in the editor.
2. 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.
3. 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.
4. 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.
5. Sign and date the authorization section to allow healthcare professionals to disclose relevant health information regarding your ability to drive safely.
6. 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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