INSTRUCTIONS: CONNECTICUT NEUROLOGY MEDICAL REPORT (Form P-142N)

When a Connecticut driver has been involved in an incident that may be related to a neurological condition, they may be required to be examined by a medical professional. This examination is documented using a form P-142N. This document can be obtained from the website of the government of Connecticut.

Connecticut Neurology Medical Report P-142N Step 1: Write the date of the incident being addressed.

Connecticut Neurology Medical Report P-142N Step 2: The patient should sign and date the first two blank boxes, then submit the form to the medical professional evaluating them for completion.

Connecticut Neurology Medical Report P-142N Step 3: Enter the patient's name, date of birth and telephone number in the first three blank boxes.

Connecticut Neurology Medical Report P-142N Step 4: Enter the patient's street address, city, state and zip code in the next blank box.

Connecticut Neurology Medical Report P-142N Step 5: In the next two blank boxes, enter how long you have been treating this patient and the date of their last examination.

Connecticut Neurology Medical Report P-142N Step 6: In the next blank section, enter how many years the patient has had this condition, as well as providing a brief diagnosis, etiology and prognosis.

Connecticut Neurology Medical Report P-142N Step 7: In the next blank section, write whether the patient has any other conditions which should be evaluated by another specialist. If so, provide an explanation.

Connecticut Neurology Medical Report P-142N Step 8: In the table provided below, document episodes of altered consciousness in the last two years. Enter the date and type of each episode.

Connecticut Neurology Medical Report P-142N Step 9: In the table provided below this, document medications relevant to motor vehicle operation as instructed.

Connecticut Neurology Medical Report P-142N Step 10: Indicate whether the condition warrants periodic reporting with a check mark. If so, write the condition and the frequency with which periodic status reports should be issued in months, as well as the duration of years for which these reports should continue.

Connecticut Neurology Medical Report P-142N Step 11: Answer all remaining questions by checking "yes" or "no" as applicable.

Connecticut Neurology Medical Report P-142N Step 12: Print and sign your name at the bottom of the page, as well as providing all other identifying information requested.