Form 5108E Medical Condition Report - Ontario, Canada

MTO Medical Form Instructions

You will need to include the following information to complete the MTO Medical Form:

1. The full name of the patient, their year of birth, gender, driver's license (if applicable), and current home address.
2. Your medical office's information, including the name of the person completing the Medical Condition Report, the medical office's address, and your medical professional relationship to the patient (such as a nurse, treating physician, or occupational therapist).
3. Answers to questions asking about the patient's knowledge that an MTO Medical Form is being completed on their behalf and that you will be releasing the information to the patient or their caregiver if requested.
4. A detailed list of medical or visual disabilities that can impair the person's driving. All impairments that affect the patient's ability to operate a vehicle will need to be recorded in this section.
• Cognitive issues such as dementia, a history of strokes, alcohol or drug withdrawal. You will also be asked if these issues are recurring in the patient;
• Physical impairments such as a spinal cord injury or other impairment that affects muscle strength or control;
• Visual impairment such as sight perception under 20/50 when examined or severe lack of depth of field in the patient's vision;
• Severe substance use dependency not including caffeine or nicotine and where the patient has refused to accept a medical practitioner's recommendation for treatment;
• Psychological impairment where symptoms such as hallucinations, psychoses, or suicidal ideation occur.