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Kansas division of vehicles me... Page 1 of 2 PLEASE RETURN COMPLETED MEDICAL FORMS TO: PH: (785) 3688971 FAX: (785) 2965857STATE OF KANSAS DIRECTOR OF VEHICLES MEDICAL/VISION UNIT 300 SW 29th ST. PO BOX 2188 TOPEKA KS 666012188 KANSAS

Medical forms to 4. Specify any driving restrictions that are appropriate based on the patient s disease or medical and/or psychological condition. 5. 3. Please note that if the patient has had a recent loss or alteration of consciousness the exam date must be a full six months after the date of the last occurrence. SECTION I PHYSICIAN S REPORT In your opinion does this patient have a medical condition that could affect the patient s ability to safely operate a motor vehicle Yes No Uncertain If yes or uncertain please explain Has the patient had any loss/lapse of consciousness seizure activity fainting or syncopal event in a waking state If yes please indicate the date of the last occurrence MM/DD/YYYY Was the seizure or loss of consciousness an isolated incident Should this patient be referred to a specialist such as a neurologist or psychologist to determine their ability to safely operate a motor vehicle If yes what type Page 1 of 2 Physician s Comments Indicate below which restrictions may apply to the patient s license if issued or continued Maximum 6 restrictions. PLEASE RETURN COMPLETED MEDICAL FORMS TO PH Telephone 785 368-8971 FAX FAX 785 296-5857 STATE OF KANSAS DIRECTOR OF VEHICLES MEDICAL/VISION UNIT 915 HARRISON STREET PO BOX 2188 TOPEKA KS 66601-2188 KANSAS DIVISION OF VEHICLES MEDICAL FORM GENERAL INFORMATION HISTORY TO BE FILLED OUT BY THE PATIENT NAME DRIVER LICENSE DOB ADDRESS CITY/STATE/ZIP PHONE Currently enrolled in Driver s Education YES / NO If yes instructor name phone number RELEASE OF INFORMATION Permission is granted for release of all medical information concerning me to the Kansas Division of Vehicles by all medical professionals filling out this form. SIGNATURE OF PATIENT DATE To the Medical and/or Psychological Professionals Please complete the sections of this report applicable to this patient s conditions. All treating physicians must complete a set of forms. If you have questions please call 785-368-8971. Corrective Lenses Within City Limits Mechanical Aid Daylight Hours Only Licensed Driver in Front Seat Prosthetic Aid No Interstate Driving Outside Business Area Automatic Transmission Outside Mirror Miles From Home 5-30 in 5 mile increments Should an actual test of the patient s driving ability be administered Should an annual medical report be required to be filed with the Division of Vehicles This patient is capable of safely operating a motor vehicle. 2. Indicate yes or no whether from a medical and/or psychological standpoint only this patient is capable of safely operating a motor vehicle. The information on this form must be from an examination within the last 90 days. Instructions 1. Please answer each question and fill out the entire form carefully and legibly. You assume no responsibility in making this report other than that of truthfully representing the facts as they appear in your professional judgment. Driver must be considered a safe candidate in order to request a drive test. Does this patient require a vision exam Name of Medical Professional License Please print Date of Examination Medical Professional s Specialty Signature of Medical Professional Address Date Signed Phone.

Ct dmv medical form MEDICAL FORMSTATE OF CONNECTICUT DEPARTMENT OF MOTOR VEHICLES 60 STATE STREET, WETHERSFIELD, CT 061611013 DRIVER SERVICES DIVISION ct.gov/dmvP142M Rev. 220Department of Aging and Disability Services

Cdl self certification medical... MINNESOTA DEPARTMENT OF PUBLIC SAFETYPrint FormDRIVER AND VEHICLE SERVICESC o mme rci al D riv e r License M edical Self cer tif ication Form Instructions:All commercial driver\'s license (CDL) holders,

Ct dmv medical form 488302457 STATE OF CONNECTICUT DEPARTMENT OF MOTOR VEHICLES 60 STATE STREET, WETHERSFIELD, CT 061611013 DRIVER SERVICES DIVISION ct.gov/dmvMEDICAL FORM P142M Rev. 718Department of Rehabilitation Services/ Driver

Medical forms online health ca... medical form

Summer camp medical form 2019... HEALTH RECORD FOR CHILDREN IN DAY CAMPS & AFTERSCHOOL & YOUTH CENTERS (This side to be filled in by parent/guardian.) Name of Program: Childs Last Name: Childs First Name: Birthdate: / / Sex:

Amarnath yatra medical form COMPULSORY HEALTH CERTIFICATE FOR SARI AMARNATHJI YATRA 2018Please paste one recent passport size photograph airport A: (TO BE FILLED BY APPLICANT) 1. Name S/o;D/o; W/o Address 2. Date of Birth Identification

Evaluation of medical form SECTION 6: PISA COMPREHENSIVE INITIAL PRE-PARTICIPATION PHYSICAL EVALUATION AND CERTIFICATION OF AUTHORIZED MEDICAL EXAMINER Must be completed and signed by the Authorized Medical Examiner (AME) performing

Nc community college medical f... NAME: PROGRAM: Student Medical Form for North Carolina Community College System Institutions Revised 2003 PAGE 2 BLANK (Please print in black ink) FOR INDIVIDUAL SCHOOLS TO EDIT To be completed by

Paramedical form Paramedical Supplement to Application Insurer OM Financial Life Insurance Company Insured First Name Middle Initial Birth Date Last Name birthplace Medical History Questions 1. Have you ever been

Physical therapy medical form Physical Therapy Medical Screening Questionnaire Contact Information Name: Gender:Age:o Male o FemaleSmoker:o Yes o Pregnant:Date:o Yes o Occupation: Describe your exercise routine: Past Medical History

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