Form HSMV 72117. Loss of Consciousness Follow-up Form - Florida
The Form HSMV 72117, known as the Loss of Consciousness Follow-up Form, is a document issued by the Florida Department of Highway Safety and Motor Vehicles. This form is used to provide medical follow-up information for individuals who have experienced a loss of consciousness or an episode of unconsciousness.
The main purpose of this form is to assess the individual's fitness to drive safely after experiencing a loss of consciousness. It helps the Department determine if any restrictions or medical evaluations are necessary to ensure the individual's safety and the safety of others on the road.
The form typically consists of the following sections:
- Driver's personal information (name, address, date of birth)
- Details of the loss of consciousness episode(s), including the frequency and duration
- Information about the diagnosing physician and their contact details
- Medical evaluation and treatment information
- Declaration of the accuracy of the information provided
- Signature of the driver and diagnosing physician
When filling out this form, it is important to provide accurate and comprehensive medical information related to the loss of consciousness episodes. The diagnosing physician should carefully review and validate the information provided before signing the form. Compliance with any specific requirements or recommendations outlined by the physician or the Department is crucial for ensuring safe driving.
Additional documents that must be attached when submitting this form may include any relevant medical reports, test results, or treatment records associated with the loss of consciousness event(s). These documents aid in the evaluation process and provide a comprehensive understanding of the individual's medical history and current condition.
An example of an application for this form would be a driver who experienced a loss of consciousness due to a medical condition such as epilepsy. The Loss of Consciousness Follow-up Form allows the driver to provide updated medical information, treatment details, and any changes in their condition to assess their fitness to drive safely.
A related form is the Medical Reporting Form (Form HSMV 72190), which is used to report various medical conditions or impairments that may affect a person's ability to drive. While the Loss of Consciousness Follow-up Form specifically addresses individuals who have experienced a loss of consciousness event, the Medical Reporting Form covers a broader range of medical conditions and requires comprehensive medical information for evaluation.