DS-6574 Seizure/Epilepsy

OMB APPROVAL NO 1405-XXXX
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: XX MINUTES

U.S. Department of State

Bureau of Medical Services

DRIVER MEDICAL EVALUATION: SEIZURE/EPILEPSY
ASSESSMENT FORM
Instructions: This form is required for all individuals with epilepsy or history of one or more seizures and must be provided at the time of the initial or
periodic medical evaluation. Failure to provide this form may result in disqualification or delays in the evaluation process. This form should be
completed by the medical provider/clinician who manages the driver’s epilepsy or seizure disorder or for historical seizure(s), serves as the driver’s
treating or primary care clinician/provider.

Section I: Driver Information
Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Section II: Seizure History
HISTORY
Single Seizure Only?
Yes

Epilepsy, or seizure disorder?

No

Yes

If yes, proceed to SINGLE SEIZURE

No

If yes, proceed to EPILEPSY/SEIZURE DISORDER

SINGLE SEIZURE
When was the single seizure (enter approximate date (mm-yyyy))?
Was the seizure provoked
(i.e., there was a reason for
the seizure)?
Yes

No

Yes

No

If "Yes", risk factors for occurrence

Is the patient at increased risk for another seizure?

Does the individual have
any medical conditions
placing him/her at risk for
another seizure?
Yes

If "Yes", reason for seizure

If "Yes", describe

No

EPILEPSY/SEIZURE DISORDER
List type of seizure disorder:
Is the individual currently on
medication for epilepsy/
seizure disorder?
Yes

Name of Medication

Dose

Length of Treatment

IF YES:

Previous treatment

No

Previous treatment

IF NO:
When was the patients last seizure(enter approximate date (mm-yyyy))?
For how long has the individual been stable on his/her treatment plan (stable means consistent medication and dosage, regular follow up, etc.)? List
length of time in months/years:
Yes

No

Are the seizures well controlled by the current treatment?

RESTRICTIONS
If "Yes", provide details
Are there any local (host
nation) restrictions related to
seizures/epilepsy and
professional driving?
Yes
DS-6574
03-2024

No
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Name of Examinee

DOB

COMMENTS

Section III: Provider/Clinician Recommendation
______________ (initial): I attest that I am the individual’s treating or primary clinician with knowledge about past history
of one or more seizures and any treatment regimen.
Based on my assessment above, performed on ________________________ (mm-dd-yyyy):
The individual can safely drive, without restrictions.
The individual can safely drive with the following restrictions/limitations:
The individual should not drive at this time.
Name of Provider/Clinician

Signature of Provider/Clinician

Clinic Address/Post

Phone Number

Medical Credential/Specialty

Email

*Note: even if the documentation indicates the individual can drive, this document will be reviewed as part of the overall driver medical
evaluation and in accordance with the US Department of State Bureau of Medical Services Driver Medical Evaluation Policy.
Paperwork Reduction Act Statement
Releases or disclosures of confidential medical information are governed by the Privacy Act of 1974, as amended, 5 U.S.C. § 552a et seq., and the
Rehabilitation Act of 1973, as amended, 29 U.S.C. § 701 et seq.
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to 5 CFR 930.108, 339.301 and the Foreign Service Act of 1980, as amended (Title 22 U.S.C.
4084, 3901, and 3984).
PURPOSE: The information requested on this form will be used to determine medical eligibility for issuance of a driver medical certificate.
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
The information may also be made available to local Health Units. More information on the Routine Uses for the system can be found in the System of
Records Notice State-24, Medical Records
DISCLOSURE: Providing this information is voluntary; however, failure to provide this information may result in denial of a driver medical certification.
The Genetic Information Nondiscrimination Act of 2008 (GINA)
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008
(GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you NOT provide any genetic
information when responding to this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical
history, the results of an individual's or family members' genetic tests, the fact that an individual or an individual's family member sought or received
genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual
or family member receiving assistive reproductive services.
DS-6574

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