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1 Page 1 of 4 Original document in FrenchSoci t de l assurance automobile du Qu bec28 Medical Examination Report Driver s LicenceNotice to readers: This document complies with Qu bec government standard S G Q R I 0 0 8 - 0 2 on the accessibility of downloadable documents. If you experience difficulties, please contact us at: 1 800 3 6 1 7 6 2 VISUAL DISORDERSD efect detected during confrontation visual field testingDiplopia within the central 40 degrees Pseudophakia RetinopathyBilateral cataracts Glaucoma AMDV isual acuity based on the Snellen Chart:2 HEARING DISORDERS3 NEUROLOGICAL DISORDERSP resence of a hearing disorder that requires or would require the use of a hearing aidIs the person able to understand a sentence uttered in a forced whisper at a distance of metres?

2 With a hearing aidWithout a hearing aidNOPROCEED TO THE NEXT SECTIONP resence of a neurological disorder (if there are functional limitations related to the diagnosis, complete Section 10) Other: CVA Parkinson s MS Brain tumour Head traumaCurrent symptoms:Date of diagnosis(Year-Month-Day)NONOIn the following sections, check the NO box if there are no health issues to report OU 6/OU 6/Without correction:With correction: Ye s No If so, check the appropriate box or boxes:PROCEED TO THE NEXT SECTIONPROCEED TO THE NEXT SECTIONAny fees related to this report must be paid by the person undergoing the examination and do not qualify for reimbursement by the THE HEALTH CARE PROFESSIONALThe examination must take into account prior and current ailments that may affect the individual s ability to drive.

3 When reporting a health issue, be sure to check all the boxes that apply. Discuss any ailments that are not mentioned below in section sections 2840 and 2841 of the Civil Code of Qu bec, a computer reproduction of this authorization carries the same value as the hereby authorize the Soci t de l assurance automobile du Qu bec to discuss, when necessary, medical information concerning me with the health care professional who has signed this form. I understand that a summary of all communications will be kept in my of the person undergoing the examination: Telephone: Please read and sign the authorization below and read the statement regarding the protection of personal information at the bottom of page THE PERSON UNDERGOING THE EXAMINATIONDate:DDMMYYYY6228A 35 Return the original form to.

4 Service de l valuation m dicale et du suivi du comportement Soci t de l assurance automobile du Qu bec Case postale 19500, succursale Terminus Qu bec (Qu bec) G1K 8J5 Address (Number, street, apartment )MunicipalityTelephone (home)Telephone (work) of birth (Year-Month-Day)Postal codeDriver s licence numberFirst nameLast nameDDMMYYYY (2021-05)Soci t de l assurance automobile du Qu becPage 2 of 4 Original document in FrenchNONONO4 EPILEPSY OR NON-EPILEPTIC CONVULSIVE SEIZURES5 HEART AND VASCULAR DISORDERS6 RESPIRATORY DISORDERSD efibrillator:IV Must be at complete rest, confined to bed or a chair: any type of physical activitycauses discomfort and symptoms can occur even at restArrhythmia:Presence of a heart disorder that severely limits physical activityIII Marked limitation of physical activity: comfortable only at restDiagnosis: Number of episodes: Ye sAortic aneurysm requiring surgery Syncopes in the last 12 months: NoDate of diagnosis:(Year-Month-Day)Date of the last shock:(Year-Month-Day)Date of implant:(Year-Month-Day)Date of the last episode :(Year-Month-Day)Functional class:Treated successfully?

5 Specify treatment:Cause: Ye s Ye s No NoTreatment effective?Presence of a respiratory disease that limits activitiesIII Shortness of breath when walking on flat terrain compared to an individual the same age or when climbing stairsIV Shortness of breath after walking 100 metres at his or her own pace on flat terrainV Shortness of breath when dressing, when undressing or when speakingSleep apnea: Number of hours of use per day: Functional category:Oxygenotherapy: Nighttime DaytimeExcessive daytime sleepiness? If so, provide the apnea-hypopnea index: If a professional driver (Classes 1, 2, 3, 4A, 4B):Heart failure Provide the ejection fraction: %In the following sections, check the NO box if there are no health issues to report.

6 Non-epileptic convulsive seizures EpilepsyDescribe how the seizures manifest:Cause: Type of seizureDate of the First seizure(Year-Month-Day)Date of the last seizure (Year-Month-Day)Generalized, focal impaired awareness (complex partial) and absenceNocturnalFocal aware (simple partial)Date of the last seizure:(Year-Month-Day)PROCEED TO THE NEXT SECTIONPROCEED TO THE NEXT SECTIONPROCEED TO THE NEXT SECTIOND river s licence numberDiameter: cm6228A 35 (2021-05)Page 3 of 4 Original document in FrenchSoci t de l assurance automobile du Qu becNONONONOD river s licence number7 DIABETES Ye s Ye s No No Treatment:In the last six months, has the person had hypoglycemic episodes while awake that resulted in an alteration of consciousness and required the intervention of a third party?

7 How many? Does the person have a proper understanding and control of his or her diabetes? InsulinHypoglycemic agentDate of the last episode :(Year-Month-Day)Date of the last psychotic episode :(Year-Month-Day)If a professional driver (Classes 1, 2, 3, 4A, 4B):Glycated hemoglobin (HbA1c): %Presence of uncontrolled psychiatric disorders that present a risk when driving a road vehicleDiagnosis: Ye s 1 No2 or moreDoes the person have the necessary sense of self-criticism and judgment for driving?Number of psychotic episodes or episodes of acute mania in the last 12 months:Current symptoms:8 PSYCHIATRIC DISORDERS9 SUBSTANCE USE DISORDERS10 FUNCTIONAL LIMITATIONSP resence of a substance use disorder (based on the DSM-5) Type of substances:Severity: AlcoholMild (2-3 criteria) DrugsModerate (4-5 criteria) Other: Severe (6 criteria or more) Before remission: After remission: Specify the person s consumption habits (frequency and amount consumed/day):Remission start date.

8 (Year-Month-Day)Presence of a functional limitation that could present a risk when driving, or have an effect on drivingPhysical limitationCognitive limitationDiagnosis of dementiaLimitations to instrumental activities of daily living/activities of daily living Describe the impairment: Describe the impairment: Causes: Severity: Specify: in physical functioning? in cognitive functioning?Have you noticed a change over the past 12 months: Ye s Ye s No No Specify: Specify: The person is unfit to safely drive professional classes of vehicle (Class 1, 2, 3, 4A, 4B) Specify: PROCEED TO THE NEXT SECTIONPROCEED TO THE NEXT SECTIONPROCEED TO THE NEXT SECTIONPROCEED TO THE NEXT SECTIONIn the following sections, check the NO box if there are no health issues to report.

9 6228A 35 (2021-05)Soci t de l assurance automobile du Qu becPage 4 of 4 Original document in French Class of medicationName of DoseFrequencyNO11 CURRENT MEDICATION12 RECOMMENDATIONS Ye s NoUse of medication of the following classes: AntipsychoticsOther (enclose a list) Anticonvulsants Antidepressants Opioids/NarcoticsAnxiolytics/Sleep aidsDescribe the side effects and their severity:When taking this medication, does the person experience side effects that affect his or her ability to drive safely (decrease in vigilance or psychomotor retardation, drug interactions, polypharmacy, etc.)?Do you believe the SAAQ should require the person to submit to additional assessments regarding his or her fitness to drive?

10 Road test by an SAAQ examiner: Functional assessment by an occupational therapist: Specialized consultations: If so, specify the specialties: Should the person cease driving while awaiting these assessments? Ye s Ye s Ye s Ye s No No No NoINFORMATION REGARDING THE HEALTH CARE PROFESSIONALA ttach any documents you feel are relevant to the of Personal InformationAll personal information gathered by authorized Soci t de l assurance automobile du Qu bec (SAAQ) personnel is handled confidentially. The SAAQ requires this information to apply the laws it is responsible for administering, in particular the Highway Safety Code, the Automobile Insurance Act and the Act respecting remunerated passenger transportation by automobile.