INSTRUCTIONS: CONNECTICUT INITIAL MEDICAL REQUEST (Form P-40)

When a Connecticut driver has been involved in an accident that may have been caused by an underlying medical condition, they may be required to receive an examination from a medical professional. This can be documented using a form P-40. This document can be obtained from the website of the government of Connecticut.

Connecticut Initial Medical Request P-40 Step 1: At the top right-hand corner, enter the driver's license number and the date of the incident in question.

Connecticut Initial Medical Request P-40 Step 2: The patient should enter their signature and the date in the first two blank boxes, then give the form to the examining medical professional for completion.

Connecticut Initial Medical Request P-40 Step 3: Enter the patient's last name, first name and middle initial in the third blank box.

Connecticut Initial Medical Request P-40 Step 4: Enter the patient's date of birth in the fourth blank box.

Connecticut Initial Medical Request P-40 Step 5: Enter the patient's telephone number in the fifth blank box.

Connecticut Initial Medical Request P-40 Step 6: Enter the patient's street address, city, state and zip code in the sixth blank box.

Connecticut Initial Medical Request P-40 Step 7: In the next section, place a check mark next to all listed conditions which may apply to the patient. The listed conditions are alcohol/substance abuse, Alzheimer's/dementia, cardiovascular/hypertension, cerebral palsy, cystic fibrosis, endocrine/glandular, liver/renal failure, narcolepsy, neurological/neuromuscular, ophthalmologic, orthopedic, peripheral vascular disease, psychiatric/emotional disorder, pulmonary/sleep apnea, or other. If the latter, provide a description.

Connecticut Initial Medical Request P-40 Step 8: In the next section, enter the conditions for which you have been treating the patient, the date on which treatment began and the date of the last examination.

Connecticut Initial Medical Request P-40 Step 9: If the patient has been treated by another physician, enter their name, office address and that physician's specialty.

Connecticut Initial Medical Request P-40 Step 10: If you believe the patient has no medical matters which would affect safe motor vehicle operation, indicate this with a check mark. If you do not have sufficient information to evaluate their ability to operate a motor vehicle safely, indicate this with a check mark. If you believe the patient should be road tested or evaluated for special equipment requirements, indicate this with a check mark.