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Form P-142R Respiratory Diseases

Form P-142R Respiratory Diseases

 

 

INSTRUCTIONS: CONNECTICUT RESPIRATORY DISEASES (Form P-142R)

 

 

 

When a Connecticut driver is referred to the state Department of Motor Vehicles over concerns regarding their ability to operate a motor vehicle safely due to a respiratory disease, a form P-142R is used to submit the evaluation of a medical professional. This document can be obtained from the website of the government of Connecticut.

 

Connecticut Respiratory Diseases P-142R Step 1: The patient will enter their signature in the first blank box and the date in the second blank box to authorize the release of the medical report in question and related materials to the Department of Motor Vehicles. The remainder of the form should be completed by the medical professional.

 

Connecticut Respiratory Diseases P-142R Step 2: Enter the patient's name in the third blank box.

 

Connecticut Respiratory Diseases P-142R Step 3: Enter the patient's date of birth in the fourth blank box.

 

Connecticut Respiratory Diseases P-142R Step 4: Enter the patient's telephone number in the fifth blank box.

 

Connecticut Respiratory Diseases P-142R Step 5: Enter the patient's full address in the sixth blank box.

 

Connecticut Respiratory Diseases P-142R Step 6: Enter the date of the patient's last examination and how long you have been treating them in the seventh blank box.

 

Connecticut Respiratory Diseases P-142R Step 7: Indicate with a check mark whether the patient has asthma, sleep apnea, chronic obstructive pulmonary disease or other. If the latter, provide an explanation.

 

Connecticut Respiratory Diseases P-142R Step 8: Indicate whether this is a progressive illness with a check mark. If yes, comment on the progress of the illness.

 

Connecticut Respiratory Diseases P-142R Step 9: Indicate whether special aids or devices must be utilized while the patient is operating a motor vehicle with a check mark. If yes, specify.

 

Connecticut Respiratory Diseases P-142R Step 10: Indicate with a check mark whether the patient is capable of exhaling 1000cc of air in one continuous breath during operation of an ignition interlock device. If no, provide an explanation.

 

Connecticut Respiratory Diseases P-142R Step 11: Indicate with a check mark whether you believe the patient understands the risk posed by their condition that may affect safe motor vehicle operation.

 

Connecticut Respiratory Diseases P-142R Step 12: Answer all remaining questions as instructed and provide all required identifying information at the bottom of the form.

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