INSTRUCTIONS: CONNECTICUT DIABETES MEDICAL REPORT (Form P-142D)

When a Connecticut driver is involved in an incident that may be related to diabetes, they may be required to undergo an exam by a medical professional. The results of this examination are documented on a form P-142D. This document can be obtained from the website of the government of Connecticut.

Connecticut Diabetes Medical Report P-142D Step 1: Enter the date of the incident being addressed in the top right hand corner.

Connecticut Diabetes Medical Report P-142D Step 2: In the first two blank boxes, the patient should enter their signature and the date. The form should then be submitted to the medical professional performing the examination, who will complete the remainder.

Connecticut Diabetes Medical Report P-142D Step 3: Enter the patient's last name, first name and middle initial in the third blank box.

Connecticut Diabetes Medical Report P-142D Step 4: Enter the patient's date of birth in the fourth blank box.

Connecticut Diabetes Medical Report P-142D Step 5: Enter the patient's telephone number in the fifth blank box.

Connecticut Diabetes Medical Report P-142D Step 6: Enter the patient's street address, city, state and zip code in the sixth blank box.

Connecticut Diabetes Medical Report P-142D Step 7: Enter the date on which the onset of diabetes was documented in the seventh blank box.

Connecticut Diabetes Medical Report P-142D Step 8: In the eight blank box, enter the amount of time you have been treating this patient for diabetes.

Connecticut Diabetes Medical Report P-142D Step 9: In the ninth blank box, enter how often you see this patient regarding diabetes.

Connecticut Diabetes Medical Report P-142D Step 10: In the tenth blank box, enter the date of the last examination.

Connecticut Diabetes Medical Report P-142D Step 11: The next section concerns current therapy. Answer all questions as directed.

Connecticut Diabetes Medical Report P-142D Step 12: The next section requires you to document associated clinical phenomena by checking "yes" or "no" in the appropriate column in response to each question and providing all supplemental information requested.

Connecticut Diabetes Medical Report P-142D Step 13: Answer all remaining questions by checking "yes" or "no" and providing all supplemental information requested.

Connecticut Diabetes Medical Report P-142D Step 14: Print and sign your name and provide all identifying information requested at the bottom of the form.