DUI Stop Medical and Physical Condition Statement Template

[Your Full Name]

[Your Street Address]

[City, State/Province, ZIP/Postal Code]

[Phone Number]

[Email Address]

[Date]

[Name of Court / Agency / DMV]

Attn: [Judge’s Name / Hearing Officer / Probation Officer, if known]

[Street Address]

[City, State/Province, ZIP/Postal Code]

1. Case Information and Purpose of Statement

Re: DUI Case [Case Number] – Medical and Physical Condition Statement for DUI Stop on [Date of Incident]

I, [Your Full Name], am providing this statement to explain certain medical and physical conditions, as well as any medications, that may have affected my appearance, behavior, or performance on field sobriety tests during the DUI stop that occurred on [Date of Incident] in [City, State/Province]. The purpose of this statement is to give additional factual information about my health and physical limitations at the time of the incident.

2. Brief Description of the DUI Stop

On [Date of Incident] at approximately [Time], I was stopped by [Name of Law Enforcement Agency, if known] while driving in the area of [Location/Street(s), City]. During the stop, I was asked to [briefly describe: “perform field sobriety tests,” “follow certain instructions,” “step out of the vehicle,” etc.].

The officer’s observations and my performance on these tests may have been influenced by the medical and physical conditions described below.

3. Medical and Physical Conditions

I have been diagnosed with the following medical and/or physical conditions that are relevant to my balance, coordination, mobility, or overall appearance:

• Condition 1: [Name of condition, e.g., “Chronic knee injury,” “Vertigo,” “Diabetes,” “Neuropathy,” “Inner ear disorder,” etc.]

  • Date of diagnosis (if known): [Date or “Approx. Year”]

  • Treating provider: [Doctor’s Name / Clinic Name]

  • Typical symptoms: [e.g., “difficulty walking long distances,” “trouble balancing on one leg,” “dizziness,” “numbness in feet,” etc.]

• Condition 2: [Name of condition]

  • Date of diagnosis: [Date or “Approx. Year”]

  • Treating provider: [Doctor’s Name / Clinic Name]

  • Typical symptoms: [brief description]

Condition 1: [Name of condition, e.g., “Chronic knee injury,” “Vertigo,” “Diabetes,” “Neuropathy,” “Inner ear disorder,” etc.]

• Date of diagnosis (if known): [Date or “Approx. Year”]

• Treating provider: [Doctor’s Name / Clinic Name]

• Typical symptoms: [e.g., “difficulty walking long distances,” “trouble balancing on one leg,” “dizziness,” “numbness in feet,” etc.]

Date of diagnosis (if known): [Date or “Approx. Year”]

Treating provider: [Doctor’s Name / Clinic Name]

Typical symptoms: [e.g., “difficulty walking long distances,” “trouble balancing on one leg,” “dizziness,” “numbness in feet,” etc.]

Condition 2: [Name of condition]

• Date of diagnosis: [Date or “Approx. Year”]

• Treating provider: [Doctor’s Name / Clinic Name]

• Typical symptoms: [brief description]

Date of diagnosis: [Date or “Approx. Year”]

Typical symptoms: [brief description]

[Add additional conditions as needed. If you have many conditions, you may summarize the most relevant ones here and refer to attached medical records.]

4. How These Conditions May Have Affected the DUI Stop and Testing

The above conditions affect my daily life in the following ways that may be relevant to the DUI stop and field sobriety tests:

• Balance and walking:

  [Example: “I often have difficulty walking heel-to-toe in a straight line, even when I have not consumed any alcohol, due to pain and instability in my knees and ankles.”]

• Standing and coordination:

  [Example: “Standing on one leg or maintaining certain positions for more than a few seconds can be very challenging because of my [back problems/vertigo/neuropathy].”]

• Eye movements or vision (if applicable):

  [Example: “I have a condition that affects my eye movements and can cause involuntary jerking or abnormal tracking, which may appear similar to intoxication.”]

• Speech, breathing, or appearance (if applicable):

  [Example: “My medical condition and medications sometimes cause slurred or slowed speech, fatigue, or shakiness, even when I am not impaired by alcohol.”]

Balance and walking:

[Example: “I often have difficulty walking heel-to-toe in a straight line, even when I have not consumed any alcohol, due to pain and instability in my knees and ankles.”]

Standing and coordination:

[Example: “Standing on one leg or maintaining certain positions for more than a few seconds can be very challenging because of my [back problems/vertigo/neuropathy].”]

Eye movements or vision (if applicable):

[Example: “I have a condition that affects my eye movements and can cause involuntary jerking or abnormal tracking, which may appear similar to intoxication.”]

Speech, breathing, or appearance (if applicable):

[Example: “My medical condition and medications sometimes cause slurred or slowed speech, fatigue, or shakiness, even when I am not impaired by alcohol.”]

Because of these ongoing issues, my performance on field sobriety tests or my appearance at the time of the stop may not accurately reflect alcohol impairment alone.

5. Medications and Treatment (If Applicable)

At the time of the DUI stop, I was taking the following prescribed medications and/or receiving treatment related to my conditions:

• Medication 1: [Name of medication]

  • Prescribing provider: [Doctor’s Name / Clinic Name]

  • Dosage and schedule: [e.g., “10 mg twice daily”]

  • Purpose: [e.g., “for chronic pain,” “for anxiety,” “for sleep,” etc.]

• Medication 2: [Name of medication]

  • Prescribing provider: [Doctor’s Name / Clinic Name]

  • Dosage and schedule: [details]

  • Purpose: [details]

Medication 1: [Name of medication]

• Prescribing provider: [Doctor’s Name / Clinic Name]

• Dosage and schedule: [e.g., “10 mg twice daily”]

• Purpose: [e.g., “for chronic pain,” “for anxiety,” “for sleep,” etc.]

Prescribing provider: [Doctor’s Name / Clinic Name]

Dosage and schedule: [e.g., “10 mg twice daily”]

Purpose: [e.g., “for chronic pain,” “for anxiety,” “for sleep,” etc.]

Medication 2: [Name of medication]

• Prescribing provider: [Doctor’s Name / Clinic Name]

• Dosage and schedule: [details]

• Purpose: [details]

Dosage and schedule: [details]

Purpose: [details]

[Optional: Briefly describe any side effects that may be relevant, such as drowsiness, dizziness, or coordination problems, if they are known and documented.]

I have been following my doctor’s instructions regarding these medications and treatment.

6. Supporting Documentation

I can provide, or have attached, the following supporting documents regarding my medical conditions and treatment (as available and permitted):

• Letters or reports from my treating physician(s) describing my diagnoses and limitations.

• Copies of relevant medical records, test results, or imaging reports.

• A medication list or pharmacy printout showing prescribed medications at the time of the DUI stop.

Letters or reports from my treating physician(s) describing my diagnoses and limitations.

Copies of relevant medical records, test results, or imaging reports.

A medication list or pharmacy printout showing prescribed medications at the time of the DUI stop.

[If attaching documents, briefly list them, e.g., “Exhibit A – Physician Letter dated [Date],” “Exhibit B – Medication List,” etc.]

7. Closing Statement and Certification

I am providing this information to help the Court / agency / DMV / probation understand my medical and physical condition at the time of the DUI stop. To the best of my knowledge, the information in this statement is true, complete, and based on my medical records and personal experience with these conditions.

I understand that this statement may be considered along with other evidence in my case, and I am prepared to answer further questions or provide additional documentation if requested through my attorney or as directed by the Court or agency.

Respectfully submitted,

[Your Full Name]

[Signature, if printed]

[Date]