Any illness or injury in last 5 years
Head/Brain injuries, disorders or illnesses
Seizures, epilepsy
medication ____________________
Eye disorders or impaired vision (except corrective lenses)
Ear disorders, loss of hearing or balance
Heart disease or heart attack, other cardiovascular condition
medication ____________________
Heart surgery (valve replacement/ bypass, angioplasty, pacemaker) 
High blood pressure
medication ____________________
Muscular disease
Shortness of breath
Lung disease, emphysema, asthma, chronic bronchitis
Kidney disease, dialysis
Liver disease
Digestive problems
Diabetes or elevated blood sugar controlled by:
diet
pills
insulin
Nervous or psychiatric disorders, e.g., severe depression
medication ____________________
Loss of, or altered consciousness
Fainting, dizziness
Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
Stroke or paralysis
Missing or impaired hand, arm, foot, leg, inger, toe
Spinal injury or disease
Chronic low back pain
Regular, frequent alcohol use 
Narcotic or habit forming drug use
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Enter the necessary information in each segment to fill in the PDF dl 51 dmv form
Type in the data in the yes no, yes no, yes no, Any illness or injury in last, 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 or altered consciousness, and Fainting dizziness Sleep disorders area.
Jot down the necessary details when you find yourself on the DRIVER LICENSE NUMBER, NAME, DATE OF EXAM, MeDiCal eXaMineR CoMPletes, QualiFieD, not QualiFieD, Check each item in appropriate box, vision numerical readings must be, standard at least acuity snellen, numerical readings must be provided, aCuity unCoRReCteD CoRReCteD, Right Eye, Left Eye, Right Eye, and Left Eye segment.
You need to specify the rights and obligations of the sides in the TELEPHONE NO, LICENSE NOSTATE OF ISSUE, SIGNATURE X, heaRinG numerical readings must, standard a Must irst perceive, Check if hearing aid used for tests, Check if hearing aid required to, INSTRUCTIONS To convert, numerical readings must be recorded, RiGht eaR, leFt eaR, RiGht eaR, leFt eaR, hz hz hz hz hz hz, and a Record distance from individual section.
Finish the template by looking at all these sections: year if or less Onetime, RECORD PULSE RATE, or higher, Stage, NA Driver not qualified, laBoRatoRy anD otheR test, urinalysis is required Protein, OTHER TESTING DESCRIBE AND RECORD, SP GR, PROTEIN, BLOOD, SUGAR, uRine sPeCiMen, Page of, and DL REV WWW.
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