Santé des conducteurs

Forms

The forms on this page are for the exclusive use of health professionals who do not have an address in Québec.

This section contains all the forms used by the SAAQ’s medical assessment and behaviour monitoring unit, called the Service de l’évaluation médicale et du suivi du comportement (SEMSC). When the SAAQ asks a driver’s licence holder to provide a medical report, it sends that person one of these forms, which must then be completed by a health care professional.

We have begun converting these medical forms in order to provide interactive versions that can be completed onscreen. The following forms have already been converted and can be completed onscreen: Medical Examination Report, Vision Examination Report by an Ophthalmologist or an Optometrist, Functional Assessment Report on Physical and Mental Fitness to Drive and the Declaration of Unfitness to Drive a Motor Vehicle. Interactive versions of the remaining forms will be made available progressively.  

At this point in time, you must still print out any interactive forms that you complete onscreen and file a paper copy with the SEMSC. However, you should be able to begin filing these forms electronically once our current computer systems have been replaced.  

Note: You must work with the existing layout of the forms. The space provided for your answers cannot be increased and the layout of the various sections cannot be changed. If the space provided is insufficient, you can attach a separate sheet.


Medical Examination Report M-28 (6228A-35) (PDF, 298.0 ko)
4 pages

This report serves to assess a driver’s overall state of health.


Vision Examination Report by an Ophthalmologist or an Optometrist M-5 (6205A-35) (PDF, 340.8 ko)
2 pages

This report is requested when a driver’s vision needs to be assessed.


Functional Assessment Report on Physical and Mental Fitness to Drive M-57 (5790A-30) (PDF, 870.3 ko)
6 pages

This report is requested when a functional assessment of a person’s physical and mental fitness to drive a road vehicle is required. A road test is involved.


Road Test Report by an Occupational Therapist M-58 (5890A-40) (PDF, 258.4 ko)This file does not meet the Web accessibility standard.
2 pages

This report is requested when the results of a road test are required in order to reassess a person’s fitness to drive.


Medical Cardiovascular Examination Report M-11 (6211A-40) (PDF, 176.9 ko)This file does not meet the Web accessibility standard.
2 pages

This report is requested when a driver’s cardiovascular health needs to be assessed.


Medical Psychiatric Examination Report M-13 (6213A-40) (PDF, 191.7 ko)This file does not meet the Web accessibility standard.
2 pages

This report is requested when a driver’s psychiatric health needs to be assessed.


Medical Neurological Examination Report M-14 (6214A-40) (PDF, 187.1 ko)This file does not meet the Web accessibility standard.
2 pages

This report is requested when a driver’s neurological health needs to be assessed


Medical Otorhinolaryngological Examination Report M-18 (6218A-40) (PDF, 154.9 ko)This file does not meet the Web accessibility standard.
2 pages

This report is requested when a driver’s hearing, or any otorhinolaryngological (ear, nose and throat (ENT)) condition, needs to be assessed.


Medical Examination Report on a Diabetic Person’s Fitness to Safely Operate a Motor Vehicle M-90 (5903A-40) (PDF, 203.8 ko)This file does not meet the Web accessibility standard.
3 pages

This report is requested when the health of a driver with diabetes needs to be assessed.


Disabled Parking Permit Application(6375A-50) (PDF, 359.7 ko)
2 pages

This form serves to assess the disability and limitations of a person with a disability.


Disabled Parking Permit Application – Motorcycles and Scooters (6402A-30) (PDF, 109.4 ko)
1 page

This form serves to apply for a disabled parking permit for a motorcycle or a scooter.


Declaration of Illness or Functional Impairment (6080A-40) (PDF, 134.4 ko)This file does not meet the Web accessibility standard.
1 page

This questionnaire is completed by an individual in order to report any new health problem, or when applying for a driver’s licence or to add a new class to an existing licence.


Declaration of Unfitness to Drive a Motor Vehicle (5626A-30) (PDF, 119.2 ko)
1 page

This form is sent to the SAAQ by a health professional who considers that the state of health of a patient renders that person unfit to drive.


 

Last update: December 16, 2021