
MEDICAL HISTORY PAGE
NOTE: TO BE COMPLETED BY YOUR PERSONAL PHYSICIAN (M.D. or D.O.)
MEDICAL HISTORY AND STATUS for:
Name of Applicant as it appears on Medical Records (if
Name of Applicant (as listed on the State-issued
Driver License or Non- Driver ID Card; or IDNYC):
Applicant’s Date of Birth - -
-designated physician will review the application and supporting medical documents. The decision will be
based on the information you provide that supports a serious impairment of mobility, as defined in Section 16
-02 of
Title 24 of the Rules of the City of New York.
Conditions or impairments (Select at least one):
Complete monoplegia or paraplegia of lower extremities.
Above ankle amputation of lower extremities, at the discretion of the examining physician. Well-fitted below the
knee prosthesis with normal ambulatory gait should not routinely be regarded as mobility impaired.
Arthritis of two major weight bearing joints of the lower extremities with clearly substantial X-rays changes
and/or MRI changes, such as loss of joint space, severe degenerative changes plus one or more of the following:
(1) Objective finding of sizable effusion of joint(s) detected by clinical examination
(2) Gross instability or valgus/varus deformities of joint(s) detected by clinical examination
(3) Ankylosis or contracture of major joint(s) to such a degree as to preclude stair climbing.
Joint replacement does not qualify by itself unless accompanied by one or more of the above criteria.
Severe atrophy of one or both lower extremities (or discrepancy in leg lengths greater than three inches) which
clearly and seriously impairs mobility.
Spinal column abnormalities of severe degree with unequivocal motor involvement not amenable to bracing or
surgery which would seriously and permanently impair mobility. X
-ray evidence of arthritis of the spine with or without
pain is insufficient reason for approval.
CT scan, MRI and/or EMG results must be available for review prior to a
Neurological conditions
, such as multiple sclerosis, myasthenia gravis, myopathies, Parkinsonism and Alzheimer's
Disease, affecting both lower extremities that would seriously impair mobility. Objective
documentation (i.e., MRI,
EMG, nerve conduction studies, et al.) must be submitted, where appropriate, by the applicant.
Cardiovascular and peripheral vascular disease of severe degree resulting in mobility impairment.
Cardiovascular disease must meet
AHA Class III or IV criteria; stress test, echocardiogram, Doppler, 6-minute walk
test or other diagnostic studies must support evidence of significant pathology and/or disability.
Pulmonary disease with documented evidence of severe obstructive or restrictive disease on pulmonary function
testing. Evidence of use of supplemental oxygen for more than twelve hours per day may also be acceptable evidence
of impairment.
Renal insufficiency requiring frequent renal dialysis with significant objective finding of neural or hemic
Malignancies of any category that require chemotherapy and/or radiation therapy or other medical
interventions which continuously and seriously impair mobility.
Post-Polio syndrome that on examination clearly and seriously impairs mobility.
AIDS related conditions, including peripheral neuropathy, wasting syndrome, dementia, which clearly seriously
impair mobility on physical examination.
Mental conditions resulting in intellectual disability of a severe nature documented by appropriate psychological
evaluation, which permanently and seriously impair mobility.
Congenital diseases of any type that clearly result in permanent serious mobility impairment, including cerebral
palsy, spina bifida and Down syndrome.
Any other permanent disability that in the specific circumstances, would seriously impair the mobility of the
applicant, including but not limited to:
Legally blind or severely visual impaired per NY State definition.
Has a physical or mental impairment or condition not listed above which constitutes an equal degree of disability,
and which imposes an unusual hardship with ambulation and prevents the person from getting around without great
difficulty. (please describe)
New York City Department of Transportation
Permits and Customer Service
30-30 Thomson Avenue, 2
nd
Floor
Long Island City, NY 11101-3045
718-433-3100, TTY 212-504-4115
NYC PPPD – February 25, 2025