Israel Ministry of Transport — Medical Examination Form for Driving-License Renewal (Private/Two-Wheeled/Tractor)

Fields

• idNumber string required

  Applicant's national identity number.

• licenseGrade enum required

  The driving-license category this medical-examination form covers, matching the form's own subtitle (private/two-wheeled categories or tractor).

  enum: A1 | A2 | B | TRACTOR
• licenseNumber string required

  Applicant's driving-license number.

• birthYear integer required

  Applicant's year of birth.

• renewalDate date required

  The date the applicant's driving license is due for renewal, triggering this mandatory medical examination.

• existingRestrictions string optional

  Existing restriction codes already printed on the applicant's driving license, if any.

• rightEyeAcuityWithoutGlasses boolean required

  Whether the right eye, tested without glasses, meets the required minimum visual acuity of 6/12.

• rightEyeAcuityWithGlasses boolean required

  Whether the right eye, tested with glasses, meets the required minimum visual acuity of 6/12.

• rightEyeVisualField boolean required

  Whether the right eye meets the required minimum visual field of 120 degrees.

• leftEyeAcuityWithoutGlasses boolean required

  Whether the left eye, tested without glasses, meets the required minimum visual acuity of 6/12.

• leftEyeAcuityWithGlasses boolean required

  Whether the left eye, tested with glasses, meets the required minimum visual acuity of 6/12.

• leftEyeVisualField boolean required

  Whether the left eye meets the required minimum visual field of 120 degrees.

• bothEyesAcuityWithoutGlasses boolean required

  Whether the both eyes together, tested without glasses, meets the required minimum visual acuity of 6/12.

• bothEyesAcuityWithGlasses boolean required

  Whether the both eyes together, tested with glasses, meets the required minimum visual acuity of 6/12.

• bothEyesVisualField boolean required

  Whether the both eyes together meets the required minimum visual field of 120 degrees.

• binocularVisionDiplopiaTestRow1 boolean required

  Result of binocular-vision/diplopia identification test row 1 of 4, in which the examiner checks whether the applicant correctly identifies the reference number of objects printed on the form for this row (2).

• binocularVisionDiplopiaTestRow2 boolean required

  Result of binocular-vision/diplopia identification test row 2 of 4, in which the examiner checks whether the applicant correctly identifies the reference number of objects printed on the form for this row (2).

• binocularVisionDiplopiaTestRow3 boolean required

  Result of binocular-vision/diplopia identification test row 3 of 4, in which the examiner checks whether the applicant correctly identifies the reference number of objects printed on the form for this row (3).

• binocularVisionDiplopiaTestRow4 boolean required

  Result of binocular-vision/diplopia identification test row 4 of 4, in which the examiner checks whether the applicant correctly identifies the reference number of objects printed on the form for this row (4).

• visionExaminerStampAndSignature string required

  Stamp and signature of the ophthalmologist or licensed optometrist who conducted the vision examination.

• visionExamDate date required

  Date the vision examination in Section A was conducted.

• applicantQ1RecurringDizzinessBalanceOrConsciousness boolean required

  Applicant's self-declared answer: have there been recurring episodes of dizziness, loss of balance, or loss of consciousness?

• physicianQ1Dizziness boolean required

  Physician's assessment: is the examinee known to have recurring episodes of dizziness?

• physicianQ1LossOfBalance boolean required

  Physician's assessment: is the examinee known to have recurring episodes of loss of balance?

• physicianQ1LossOfConsciousness boolean required

  Physician's assessment: is the examinee known to have had loss of consciousness (excluding vasovagal episodes in the last 3 years)?

• applicantQ2EpilepsyDiagnosed boolean required

  Applicant's self-declared answer: have you been diagnosed with epilepsy?

• physicianQ2EpilepsyDiagnosed boolean required

  Physician's assessment: has the examinee been diagnosed with epilepsy?

• applicantQ3StrokeSinceLicenseIssuedOrRenewed boolean required

  Applicant's self-declared answer: have you had a stroke event since the driving license was issued or last renewed?

• physicianQ3StrokeOrHeadInjuryWithResidualDeficit boolean required

  Physician's assessment: is the examinee known to have had a stroke or severe head injury resulting in significant residual sensory or motor functional impairment (e.g. limb weakness, coordination disorder/ataxia, visual-field defect, aphasia, cognitive deficits)?

• applicantQ4DegenerativeDiseaseDiagnosed boolean required

  Applicant's self-declared answer: have you been diagnosed with a degenerative disease (Parkinson's, multiple sclerosis, ALS, or other)?

• applicantQ4DegenerativeDiseaseType enum optional

  Which degenerative disease the applicant circled on the form, when applicantQ4DegenerativeDiseaseDiagnosed is true.

  enum: PARKINSONS | MULTIPLE_SCLEROSIS | ALS | OTHER
• applicantQ4DegenerativeDiseaseOtherSpecify string optional

  Free-text description of the degenerative disease, when applicantQ4DegenerativeDiseaseType is OTHER.

• physicianQ4NeurodegenerativeDiseaseDiagnosed boolean required

  Physician's assessment: is the examinee known to have a progressive neurodegenerative disease (Parkinson's, MS, ALS, or other)?

• applicantQ5NewMovementLimitation boolean required

  Applicant's self-declared answer: do you have a new movement limitation (right/left hand, right/left leg) since the license was issued or last renewed, due to decreased sensation, weakness, paralysis, or amputation?

• physicianQ5SensoryOrMotorDisturbance boolean required

  Physician's assessment: is the examinee known to have sensory and/or motor disturbances (e.g. joint stiffness, loss of range of motion, limb weakness, or uncompensated limb amputation)?

• applicantQ6DiagnosedDiabetes boolean required

  Applicant's self-declared answer: have you been diagnosed with diabetes?

• applicantQ6TreatedWithInsulin boolean required

  Applicant's self-declared answer: are you treated with insulin?

• applicantQ6RecentHypoglycemia boolean required

  Applicant's self-declared answer: have you been diagnosed in the past year with episodes of acute drop in blood-sugar level (hypoglycemia) related to diabetes?

• applicantQ6HypoglycemiaLastEventDate date optional

  Date of the most recent hypoglycemic event, when applicantQ6RecentHypoglycemia is true.

• applicantQ6RetinopathySurgery boolean required

  Applicant's self-declared answer: have you had surgery for diabetic retinopathy?

• physicianQ6RecentHypoglycemia boolean required

  Physician's assessment: is the examinee known to have had hypoglycemic events in the past year?

• physicianQ6RetinopathySurgery boolean required

  Physician's assessment: is the examinee known to have had surgery for diabetic retinopathy?

• applicantQ7HeartDiseaseOrArrhythmia boolean required

  Applicant's self-declared answer: have you been diagnosed with heart disease or a heart-rhythm disorder?

• physicianQ7UnstableHeartDiseaseOrArrhythmia boolean required

  Physician's assessment: does the examinee have unstable heart disease or an unstable heart-rhythm disorder?

• applicantQ8PsychiatricHospitalization boolean required

  Applicant's self-declared answer: have you been psychiatrically hospitalized since the license was issued or last renewed?

• physicianQ8PsychoticEventsOrImpairedInsight boolean required

  Physician's assessment: is the examinee known to have had psychotic events, abnormal reality testing, or impaired insight?

• applicantQ9ReactionMemoryOrientationImpairment boolean required

  Applicant's self-declared answer: do you have impairments in reaction speed, memory, or orientation to time and place?

• physicianQ9ReactionMemoryOrientationOrDementia boolean required

  Physician's assessment: is the examinee known or suspected to have impairments in reaction speed, memory, orientation to time and place, or dementia?

• applicantQ10ChronicAlcoholOrDrugUse boolean required

  Applicant's self-declared answer: do you regularly consume alcohol or drugs (not for medical purposes)?

• physicianQ10ChronicAlcoholOrDrugUse boolean required

  Physician's assessment: is the examinee known to chronically use alcohol or drugs (not for medical purposes)?

• applicantQ11ExcessiveDaytimeSleepiness boolean required

  Applicant's self-declared answer: do you feel significant excessive sleepiness or fatigue, or experience dozing off during the day?

• applicantQ11SleepApnea boolean required

  Applicant's self-declared answer: do you have sleep apnea?

• applicantQ11Narcolepsy boolean required

  Applicant's self-declared answer: do you have narcolepsy?

• physicianQ11ExcessiveDaytimeSleepiness boolean required

  Physician's assessment: is the examinee known to have significant excessive daytime sleepiness or dozing off during the day?

• physicianQ11SleepApnea boolean required

  Physician's assessment: has the examinee been diagnosed with sleep apnea?

• physicianQ11Narcolepsy boolean required

  Physician's assessment: does the examinee have narcolepsy?

• applicantQ12OxygenUseRequired boolean required

  Applicant's self-declared answer: is oxygen use required while driving, due to lung disease?

• physicianQ12ChronicOxygenUse boolean required

  Physician's assessment: is the examinee known to regularly use supplemental oxygen?

• applicantQ13NeedsFurtherMirdEvaluation boolean required

  Applicant's self-declared answer: in your opinion, is further evaluation needed at the Medical Institute for Road Safety (MIRD)?

• physicianQ13PreviouslyTestedAtMird boolean required

  Physician's assessment: has the examinee ever been tested at the Medical Institute for Road Safety (MIRD)?

• applicantQ14SupportingDocumentsAttached boolean required

  Applicant's confirmation that updated visit summaries from the relevant consulting physicians are attached, required whenever any Section B item above was answered positively.

• physicianKnowledgeBasis enum required

  The physician's declared basis for their knowledge of the applicant's medical history, matching the form's own three mutually-exclusive checkbox options.

  enum: REGULAR_TREATING_PHYSICIAN_3_YEARS | NEW_IMMIGRANT_UNDER_3_YEARS | REVIEWED_ALL_HMO_RECORDS_3_YEARS
• hmoName string optional

  Name of the applicant's HMO (Kupat Holim), when the physician's basis of knowledge is being the applicant's regular treating physician or treating physician of a recent immigrant.

• applicantDeclarationDate date required

  Date the applicant signed their declaration in Section B.

• applicantPhone string optional

  Applicant's telephone number, printed alongside their declaration signature.

• physicianName string required

  Name of the physician completing Section B and the physician's certification.

• physicianLicenseNumberSignatureAndStamp string required

  The physician's medical-license number, signature, and stamp.

• physicianCertificationDate date required

  Date the physician signed the certification in Section B.