INSTRUCTIONS: CONNECTICUT ORTHOPEDIC MEDICAL REPORT (Form P-142OR)

Connecticut drivers involved in an incident in which an orthopedic incident may have caused an accident may be required to have an examination performed by a medical professional. This examination will be documented using a form P-142OR. This document may be obtained from the website maintained by the government of the state of Connecticut.

Connecticut Orthopedic Medical Report P-142OR Step 1: Enter the date of the incident being addressed at the top right-hand corner.

Connecticut Orthopedic Medical Report P-142OR Step 2: The patient should enter their signature and the date in the first two blank boxes, then give the form to the medical professional for completion.

Connecticut Orthopedic Medical Report P-142OR Step 3: Enter the name of the patient in the first blank box, their date of birth in the second blank box and their telephone number in the third blank box.

Connecticut Orthopedic Medical Report P-142OR Step 4: Enter the patient's address in the fourth blank box.

Connecticut Orthopedic Medical Report P-142OR Step 5: Enter the date of the last examination in the fifth blank box.

Connecticut Orthopedic Medical Report P-142OR Step 6: Indicate with a check mark whether this is a progressive illness. If yes, comment as to its progress.

Connecticut Orthopedic Medical Report P-142OR Step 7: Indicate with a check mark whether there are splints or appliances that should be worn while the patient is operating a motor vehicle. If yes, specify.

Connecticut Orthopedic Medical Report P-142OR Step 8: Indicate with a check mark whether you believe the patient understands the potential risk posed by their condition which may affect their ability to operate a motor vehicle.

Connecticut Orthopedic Medical Report P-142OR Step 9: Indicate with a check mark whether you believe the patient takes medications as prescribed.

Connecticut Orthopedic Medical Report P-142OR Step 10: In the blank space provided, write any abnormalities detected during the orthopedic examination. Indicate with a check mark whether there are any other conditions that should be evaluated by another specialist. If so, provide an explanation.

Connecticut Orthopedic Medical Report P-142OR Step 11: Answer the next four questions by checking "yes" or "no" as appropriate. In response to the last question, indicate what types of restrictions would make it appropriate for the patient to operate a vehicle safely. Sign and date the form and provide all identifying information requested.