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Az Medical Examination Report  Form

Az Medical Examination Report Form

Use a medical examination report template to make your document workflow more streamlined.

Class State of Issue  A  B  C  D  Other: Driver completes this section, but medical examiner is encouraged to discuss with driver. Yes No Any illness or injury in last 5 years? Head/Brain injuries, disorders or illnesses Seizures, epilepsy  Medication: Eye disorders or impaired vision (except corrective lenses) Ear disorders, loss of hearing or balance Heart disease or heart attack; other cardiovascular condition  Medication: Heart surgery (valve replacement/bypass, angioplasty,...
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