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INSTRUCTIONS: CONNECTICUT CARDIOLOGY MEDICAL REPORT (Form P-142C)

When a Connecticut driver is involved in an incident that may be related to a heart condition, a form P-142C is used to document the examination by a medical professional that may be required. This document can be obtained from the website of the government of the state of Connecticut.

Connecticut Cardiology Medical Report P-142C Step 1: Enter the date of the incident being addressed at the top right-hand corner.

Connecticut Cardiology Medical Report P-142C Step 2: The patient should enter their signature and the date in the first two blank boxes, then submit the form to the medical professional performing the examination for completion.

Connecticut Cardiology Medical Report P-142C Step 3: Enter the patient's name, date of birth and telephone number in the next three blank boxes.

Connecticut Cardiology Medical Report P-142C Step 4: Enter the patient's address in the next blank box.

Connecticut Cardiology Medical Report P-142C Step 5: In the next two blank boxes, enter the amount of time you have been treating this patient and the date of their last examination.

Connecticut Cardiology Medical Report P-142C Step 6: In the next blank box, enter all patient conditions relevant to safe operation of a motor vehicle.

Connecticut Cardiology Medical Report P-142C Step 7: In the chart provided below, document all technical reports with findings relevant to safe operation of a motor vehicle.

Connecticut Cardiology Medical Report P-142C Step 8: In the next two blank boxes, give the date and type of the patient's last episode of altered circulatory stability sufficient to interfere with operating a motor vehicle safely.

Connecticut Cardiology Medical Report P-142C Step 9: In the next six blank boxes, document all medications and their dosages relevant to motor vehicle operation taken by the patient.

Connecticut Cardiology Medical Report P-142C Step 10: In the blank space where indicated, enter any abnormalities detected on cardiac examination.

Connecticut Cardiology Medical Report P-142C Step 11: Enter the next five questions by checking "yes," "no" or "not applicable" as applicable.

Connecticut Cardiology Medical Report P-142C Step 12: Indicate whether the patient's condition warrants periodic monitoring with a check mark. If so, enter the conditions which should be monitored and your recommended monitoring intervals. Below, note any other conditions which should be evaluated by another specialist and additional comments. Sign and date the form and provide all identifying information requested.