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Az Medical Examination Report Form
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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