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Include the requested details in the Any illness or injury in last 5, medication Eye disorders or, medication , Heart surgery (valve replacement/, medication , Muscular disease, Shortness of breath Lung disease, diet pills insulin, Nervous or psychiatric disorders, medication , Loss of, Fainting, while asleep, snoring Stroke or paralysis, and For any yes answer section.

In the DRIVER LICENSE NUMBER, NAME, DATE OF EXAM, MeDiCal eXaMineR CoMPletes, QualiFieD, not, QualiFieD, Check each item in appropriate box, standard: at least 20/40 acuity, INSTRUCTIONS: When other than the, numerical readings must be, aCuity unCoRReCteD CoRReCteD, Right Eye 20/, Left Eye, and Right Eye segment, describe the important particulars.

Be sure to identify the rights and obligations of the parties inside the SIGNATURE X, standard: a) Must irst perceive, Check if hearing aid used for, Check if hearing aid required to, INSTRUCTIONS: To convert, numerical readings must be, RiGht eaR, leFt eaR, RiGht eaR, leFt eaR, 500 hz 1000 hz 2000 hz 500 hz 1000, a) Record distance from individual, b) If audiometer is used, AVERAGE, and AVERAGE part.

Prepare the template by analyzing the next areas: RECORD PULSE RATE:, 180/110 or higher, Stage 3, N/A Driver not qualified, 6 months from date of exam if, urinalysis is required, OTHER TESTING (DESCRIBE AND RECORD), PROTEIN, BLOOD, SUGAR, uRine sPeCiMen, Page 2 of 4, and DL 51 (REV.

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