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Medical report blank form Medical Examination Report FOR COMMERCIAL DRIVER FITNESS DETERMINATION 1. DRIVER'S INFORMATION Driver completes this section. Driver's Name (Last, First, Middle) Social Security No. Birthdate M/D/Y

Check medical report online sa... MEDICAL REPORT ?????? ????? ???? NAME: NATIONALITY: SEX: PASSPORT NO: ISSUE PLACE: AGE: MARITAL STATUS: ISSUE DATE: POSITION APPLIED FOR: PHOTO DEAR SIR / MADAM PLEASE, ARRANGE TO EXAMINE THE ABOVE

Cfs 602 medical report on an a... Domain: dcfs.lacounty.gov Link: http://dcfs.lacounty.gov/health/documents/ ... https://www.illinois.gov/dcfs/aboutus/notices/Documents/cfs 600.pdf Verified ..... Text link: New laws taking effect

Medical report 2018 2019 form PrintResetDRIVER ANALYSIS DIVISION 2701 S. DIRKSEN PARKWAY SPRINGFIELD, IL 62723 2177827246 www.cyberdriveillinois.comOffice of the Secretary of StateDriver Services Department Medical ReportPlease

Medical report 2013 form This report shall remain valid for three months 90 days. Signature of Individual Date of Signature SECTION II MEDICAL HEALTH To be Completed by MD/DO and/or Medical Professional NP/PA Per Illinois Administrative Code Title 92 Part 1030 all sections of this report must be completed in its entirety. Cyberdriveillinois. com Office of the Secretar of State y Driver Ser vices Depar tment Medical Report Per 625 ILCS 5/6-908 of the Driver s License Medical Review Law and 625 ILCS 5/2-123 j all medical statements or reports received by the Secretary of State shall be confidential. This information will be disclosed only as authorized by the above-referenced statutes as now or hereafter amended. SECTION I To be Completed by Driver Please print or type Pursuant to 92 Illinois Administrative Code 1030. Name Last First Driver s License Number Middle Street Address Date of Birth Gender Male Female Month Day Year City ZIP Code Agreement/Release of Information I agree to remain under the care of my physician and follow the treatment exactly as prescribed. I hereby authorize and request my physician to release information regarding my medical condition to the Illinois Secretary of State and to report any change in the status of my condition that would impair my ability to safely operate a motor vehicle. Mental Health Disorder YES NO etc. SECTION IV Additional information special restrictions etc. SECTION V MD/DO and/or Medical Professional NP/PA Name of Medical Provider Please Print Medical Provider s Address Please Print Professional License Number/State License Issued Telephone Number Unacceptable Signatures Chiropractors Residents Fellows Interns RN s LPN s Co-signatures Provider s Signature Date of Completion of Medical Health Section MD DO NP PA Provider s Specialty PLEASE MAINTAIN A COPY OF MEDICAL REPORT FOR YOUR RECORDS.. Print Reset Save DRIVER ANALYSIS DIVISION 2701 S* DIRKSEN PARKWAY SPRINGFIELD IL 62723 217-782-7246 www. 16 please complete the following information and sign the medical agreement as a condition of licensure. I understand that failure to abide by the conditions set forth in this agreement are grounds for the Secretary of State to deny or cancel my driving privileges. DATE OF COMPLETION OF MEDICAL HEALTH SECTION II YES NO In your professional opinion is this individual MEDICALLY FIT to safely operate a motor vehicle Conditions Yes or No required for each condition listed* NO provide condition a Cardiovascular YES b Neurological c Musculoskeletal d Respiratory e Seizure f Diabetes g Dizzy/Fainting Spell h Alcohol/Drug Abuse i Other Medical Condition s For mental health disorders please refer to Section III-Mental Health. Section III must be completed if the individual has a MENTAL HEALTH disorder. List all current medications prescribed relating to any condition indicated above in Question 2. If medications are listed a condition must be disclosed above in Question 2. No medications prescribed continued on back Printed by authority of the State of Illinois.

Medical report 2017 form PrintReset DRIVER ANALYSIS DIVISION 2701 S. DIRKSEN PARKWAY SPRINGFIELD, IL 62723 2177827246 www.cyberdriveillinois.comOffice of the Secretary of StateDriver Services Department Medical ReportPer

Printable utah state functiona... FUNCTIONAL ABILITY EVALUATION MEDICAL REPORT UTAH DRIVER LICENSE DIVISION TOP PORTION MUST BE COMPLETED AND SIGNED BY APPLICANT P O BOX 144501 SLC UT 84114-4501 Phone Number: (801) 957-8690 Fax Number:

Dld 134 2015 2019 form Drive test is not available for level 8 Date form is completed Printed Name of Health Care Professional and Degree Signature initials State License Number Must be submitted to Driver License within 6 months Street Address City State Zip Code Telephone Fax Number Doctor s Comments There are special considerations I would like to discuss with a representative of the Division. DLD 134 Rev. 11-15 For more information regarding the medical program or to view current medical guidelines please visit www. FUNCTIONAL ABILITY EVALUATION MEDICAL REPORT UTAH DRIVER LICENSE DIVISION TOP PORTION MUST BE COMPLETED AND SIGNED BY APPLICANT P O BOX 144501 SLC UT 84114-4501 Phone Number 801 957-8690 Fax Number 801 957-8698 Last Name First Name Middle or Maiden Name Date of Birth Driver License or DPC By signing this form I authorize my healthcare professional s to disclose specific health information regarding my physical mental and emotional condition relevant to my ability to safely operate a motor vehicle to the Utah Driver License Division* I understand that if I fail to sign this authorization my driving privilege may be affected* I understand that this information will be classified as a private record in accordance with GRAMA UCA 63G-2-202. Individuals who are entitled to have a private record disclosed to them are limited to the subject of the record a parent or legal guardian of an unemancipated minor or legally incapacitated individual an individual with power of attorney or a notarized release signed by the subject of the record or an individual with a court or legislative subpoena* APPLICANT S SIGNATURE Date Form will not be processed without signature BOTTOM PORTION TO BE COMPLETED AND SIGNED BY HEALTH CARE PROFESSIONAL The following safety assessment level is for use in determining driving privileges. It is consistent with the current edition of Functional Ability in Driving Guidelines and Standards for Health Care Professionals. Please indicate level below with a check mark and your initials. Safety Assessment Level A B C D E F G H J K Diabetes Metabolic Condition On CardioVascular High Blood Pressure Pulmonary Neurologic Seizures or Episodic Learning Memory Psychiatric Emotional Alcohol Other Drugs Musculoskeletal/ Chronic Debility Alertness Sleep Disorders N/A Yes No Inhaler Only Oxygen Date of w/Driving L Hearing Balance last seizure Please indicate if any of the following apply to this medical review Recommended Restrictions Non-standard review time frame ADD OR REMOVE Safety Assessment categories not marked are relevant and should be completed by Speed-posted 40 mph or less Area another health care professional* Please list categories which are of concern Oxygen while driving Daylight only I recommend this driver complete a driving skills test in an appropriate vehicle. FUNCTIONAL ABILITY EVALUATION MEDICAL REPORT UTAH DRIVER LICENSE DIVISION TOP PORTION MUST BE COMPLETED AND SIGNED BY APPLICANT P O BOX 144501 SLC UT 84114-4501 Phone Number 801 957-8690 Fax Number 801 957-8698 Last Name First Name Middle or Maiden Name Date of Birth Driver License or DPC By signing this form I authorize my healthcare professional s to disclose specific health information regarding my physical mental and emotional condition relevant to my ability to safely operate a motor vehicle to the Utah Driver License Division* I understand that if I fail to sign this authorization my driving privilege may be affected* I understand that this information will be classified as a private record in accordance with GRAMA UCA 63G-2-202. Individuals who are entitled to have a private record disclosed to them are limited to the subject of the record a parent or legal guardian of an unemancipated minor or legally incapacitated individual an individual with power of attorney or a notarized release signed by the subject of the record or an individual with a court or legislative subpoena* APPLICANT S SIGNATURE Date Form will not be processed without signature BOTTOM PORTION TO BE COMPLETED AND SIGNED BY HEALTH CARE PROFESSIONAL The following safety assessment level is for use in determining driving privileges.

Com search for medicalvision c... PrintResetDRIVER ANALYSIS DIVISION 2701 S. DIRKSEN PARKWAY SPRINGFIELD, IL 62723 2177827246 www.cyberdriveillinois.comOffice of the Secretary of StateDriver Services Department Medical ReportPlease

Employment and support allowan... ESAN54C 072011 004 001:ESAN0054C 13/09/2011 14:12 Page 1 Employment and Support Allowance The Pension Service Tyneview Park Newcastle upon Tyne ENGLAND NE98 1BA Medical report form Person to be examined

Medical report on an adult in... CFS 602 Rev. 9/2002 STATE OF ILLINOIS Department of Children and Family Services MEDICAL REPORT ON AN ADULT IN A CHILD CARE FACILITY (Includes employees and volunteers in DCFS licensed child care

Medical report form THE CATHOLIC UNIVERSITY OF EASTERN AFRICA A. M. E. C. E. A Infirmary MEDICAL REPORT Part I : To be completed by applicant in the presence of Medical examiner. Name in full.........................................................................................................................................................................

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