"Fitness to Drive Form"

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Fitness to Drive Form
Last Name
First Name
Middle Name
Date
Birthdate
Age
Sex
Street Address
City, State, Zip
Phone No. (Home)
Phone No. (Work)
Email
Application Type
Driver’s License No.
State
Examination Standards
License Class
qNew License
qPersonal License
q A
q C
qExisting License
qCommercial License
q B
q D
Medical History
Injury/Illness in past two years
q No q Yes q Unknown
If yes, explain:
Stroke/Paralysis
q No q Yes q Unknown
If yes, explain:
q No q Yes q Unknown
Seizures/Epilepsy
If yes, explain:
Hearing Disorder(s)
q No q Yes q Unknown
If yes, explain:
Vision Disorder(s)
q No q Yes q Unknown
If yes, explain:
Heart Condition(s)
q No q Yes q Unknown
If yes, explain:
Muscular Spasms/Disease
q No q Yes q Unknown
If yes, explain:
Spinal Injury/Disease
q No q Yes q Unknown
If yes, explain:
Amputations
q No q Yes q Unknown
If yes, explain:
Asthma/Fainting
q No q Yes q Unknown
If yes, explain:
Substance Use
q No q Yes q Unknown
If yes, explain:
q No q Yes q Unknown
Current Medication(s)
If yes, explain:
Recent Surgeries
q No q Yes q Unknown
If yes, explain:
Other
q No q Yes q Unknown
If yes, explain:
Reviewer Decision
Action Required
q The applicant is qualified for a [personal/commercial]
None.
license without further assessment.
The applicant is qualified for a conditional
q
[personal/commercial] license.
The applicant is not qualified for a [personal/commercial]
q
license without further assessment.
The applicant is not qualified for a [personal/commercial]
q
license.
Signature
Date
www.FreePrintableMedicalForms.com
Fitness to Drive Form
Last Name
First Name
Middle Name
Date
Birthdate
Age
Sex
Street Address
City, State, Zip
Phone No. (Home)
Phone No. (Work)
Email
Application Type
Driver’s License No.
State
Examination Standards
License Class
qNew License
qPersonal License
q A
q C
qExisting License
qCommercial License
q B
q D
Medical History
Injury/Illness in past two years
q No q Yes q Unknown
If yes, explain:
Stroke/Paralysis
q No q Yes q Unknown
If yes, explain:
q No q Yes q Unknown
Seizures/Epilepsy
If yes, explain:
Hearing Disorder(s)
q No q Yes q Unknown
If yes, explain:
Vision Disorder(s)
q No q Yes q Unknown
If yes, explain:
Heart Condition(s)
q No q Yes q Unknown
If yes, explain:
Muscular Spasms/Disease
q No q Yes q Unknown
If yes, explain:
Spinal Injury/Disease
q No q Yes q Unknown
If yes, explain:
Amputations
q No q Yes q Unknown
If yes, explain:
Asthma/Fainting
q No q Yes q Unknown
If yes, explain:
Substance Use
q No q Yes q Unknown
If yes, explain:
q No q Yes q Unknown
Current Medication(s)
If yes, explain:
Recent Surgeries
q No q Yes q Unknown
If yes, explain:
Other
q No q Yes q Unknown
If yes, explain:
Reviewer Decision
Action Required
q The applicant is qualified for a [personal/commercial]
None.
license without further assessment.
The applicant is qualified for a conditional
q
[personal/commercial] license.
The applicant is not qualified for a [personal/commercial]
q
license without further assessment.
The applicant is not qualified for a [personal/commercial]
q
license.
Signature
Date
www.FreePrintableMedicalForms.com