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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.........................................................................................................................................................................

Medical report intake form Medical Report Intake Form Product Liability Law Firm: Client/Case Name: Contact Person/Number: Age: Date of Injury: DOB: Date Sent to CLS: Deadline: Brief Description of Incident and Injury: Name

Medical reports request formsi... Health Information Management Services Singapore General Hospital Outram Road Singapore 169608 Tel: 6372 4696 Fax: 6321 4785 medicalreport sgh.com.sgFORM A APPLICATION & CONSENT FOR RELEASE OF

Carer payment andor carer allo... Carer Payment and/or Carer Allowance Instructions If completing form by hand: Print clearly using a black pen only Use BLOCK LETTERS Person being cared for details Medical Report (SA332a) for a person

Annual medical report form Republic of the Philippines Department of Labor and Employment National Capital Region ANNUAL MEDICAL REPORT FORM For Period January 1, to December 31, 1. Name of Establishment: 2. Address: 3. Name

Medical report intake form 394...

Medical report form 14211880 AU PAIR USA Medical Report PART I To be completed by Applicant International Cooperator Applicant s Last Name First Name Address City State/Province Postal Code Country Telephone COUNTRY CODE CITY CODE PHONE NUMBER Date of Birth Gender Male Female Height cm Weight kg MM/DD/YYYY PRIMARY EMERGENCY CONTACT Name Relationship to Applicant Email ALTERNATIVE EMERGENCY CONTACT In case of emergency if primary contact is unable to be contacted Are you covered by additional insurance beyond that provided by the InterExchange program If yes please give details Yes No Note Insurance provided by InterExchange will not cover the cost associated with any pre-existing condition. Check the appropriate box if you are presently suffering from or have ever had Anemia Epilepsy/convulsions Mental or nervous disorder Anorexia German measles Rubella Migraine/headaches Arthritis Glandular fever Mumps Asthma Hepatitis Rheumatic fever Bulimia Hernia Scarlet fever Chicken pox Herpes Tuberculosis Depression Malaria Typhoid fever Diabetes Measles Ulcers Dizziness/fainting Meningitis Other Any disease/impairment/abnormality of lood or endocrine B system ones joints musculoskeletal system Brain or nervous system Ears Eyes Gastrointestinal system If you answered yes to any of the above please give details including dates if applicable AP PA01 0811 Genitourinary system Heart ungs respiratory L Nervous system Skin Tonsils nose or throat Do you suffer from any allergies Insect sting Foods Other drugs Hay fever If you checked any of the above please give details including dates if applicable General Health Is your physical activity restricted in any way Have you ever received treatment for a nervous or emotional problem Are you currently taking any medications Do you have any habits that may affect your health i.e. alcohol cigarettes drugs Do you currently have any infectious diseases Do you have any dietary restrictions Are you pregnant Have you been hospitalized Have you ever undergone surgery I hereby certify that all information given is correct and that withholding or falsifying any information may result in me being withdrawn from the program. I also accept full responsibility for any medical expenses which are not covered by my insurance policy. SIGNATURE Important Compensation under medical expense policies for Travel Insurance Services does not include the cost of normal dental/vision treatment not due to an accident. It is therefore important for any person traveling abroad to receive thorough dental/eye examinations prior to departure so that no unexpected complications arise during the period of residence abroad. Dental/vision treatment can be very expensive in the USA. SIGNATURE Important Compensation under medical expense policies for Travel Insurance Services does not include the cost of normal dental/vision treatment not due to an accident. It is therefore important for any person traveling abroad to receive thorough dental/eye examinations prior to departure so that no unexpected complications arise during the period of residence abroad* Dental/vision treatment can be very expensive in the USA.

Connecticut medical report for... PSYCHIATRIC/SUBSTANCE ABUSE MEDICAL REPORT STATE OF CONNECTICUT DRIVER 'S LICENSE NUMBER DEPARTMENT OF MOTOR VEHICLES DRIVER SERVICES DIVISION ct.gov/dmv P-142P/S REV. 4-2011 YES CDL/PS NO MAIL TO:

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