Driving Restriction/Medical Clearance Letter (Seizure)

Medical Letter: Seizure-Related Driving Restriction or Clearance

Date: [Date]

Clinician: [Name, credentials, specialty, practice name, address, phone, fax]

State License #: [License number]

Patient: [Full legal name]

Date of Birth: [MM/DD/YYYY]

Driver's License #: [Number, if known]

Recipient: [DMV medical review unit / licensing authority / employer medical review / provided to patient for delivery]

Jurisdiction: [State/Province whose driving rules apply]

Re: Seizure-related driving evaluation for private/non-commercial driving privileges

Purpose and Clinical Relationship

[Requesting party, purpose, and scope] (State who requested this letter and whether the purpose is restriction notification, clearance request, or periodic review. If a commercial/CDL evaluation is requested, note that a separate commercial medical certification process applies.)

[Clinician role and most recent evaluation date supporting this opinion]

[Authorization status] (Note whether patient authorization for third-party disclosure is on file, or if the letter is provided to the patient for delivery.)

Clinical Summary

Diagnosis: [Seizure disorder diagnosis using current terminology, including epilepsy type/etiology if known, or single/provoked seizure. Note whether events involve loss of awareness, loss of consciousness, or loss of motor control.]

Seizure Timeline:

• Date of last seizure with impaired awareness/LOC/motor control: [MM/DD/YYYY / unknown—patient unsure] (If uncertain, state explicitly rather than inferring.)
• Seizure-free interval as of this letter: [Duration]
• Seizure frequency over past 12 months: [none / frequency description]
• Seizure-related motor vehicle incidents: [yes / no / unknown]
• Information source: [patient report / witness or caregiver report / medical records]

Current Treatment: [Antiseizure medication(s) with dose and frequency. Adherence assessment based on patient report, refill history, or drug levels. Any recent medication changes or tapering and whether this requires a temporary driving pause.]

Driving-Relevant Side Effects: [Presence or absence of sedation, dizziness, slowed reaction time, coordination impairment, visual disturbance, or cognitive effects. If none: "No driving-relevant adverse effects reported/observed."]

Counseling and Medical Opinion

Counseling Provided: [Document that the patient was counseled to stop driving immediately after any seizure affecting awareness/LOC/motor control; to avoid driving during medication changes or when experiencing medication-related impairment; and to notify the treating clinician of any breakthrough events. Note that jurisdiction-specific seizure-free interval requirements were discussed.]

Medical Opinion: In my medical opinion, the patient is [not medically fit to drive at this time / may be fit to drive with specified conditions / indeterminate pending further evaluation].

• Rationale: [Brief rationale based on seizure-free interval, treatment stability, adherence, and medication impairment status]
• Conditions: [If applicable: maintain prescribed therapy, no driving during medication changes, no driving if aura occurs, comply with follow-up] (Only include if recommending conditional fitness.)
• Reconsideration date: [MM/DD/YYYY] (Include if restricted.)
• Seizure-free and stable since: [MM/DD/YYYY] (Include if supportive.)

The licensing authority/DMV makes the final determination regarding driving privileges.

If breakthrough seizures, missed medications, or new medication-related impairment occur, the patient should immediately cease driving and contact the clinic.

Signature

Clinician Signature: ______________________________

Printed Name and Credentials: [Name, credentials]

Date Signed: [MM/DD/YYYY]

License #: [License number]

Forms/Reports Submitted: [If DMV forms were completed or a report was submitted to a medical advisory board, note form name, submission method, and date.] (Omit if none.)