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Medical Examination Report <br />FOR COMMERCIAL DRIVER FITNESS DETERMINATION <br />649 -F (6945) <br />DRIVER'S INFORMATION <br />Driver's Name (Last, First, Middle) <br />Social Security No. 6irthdale <br />Age <br />Sex ;New Cerblication r3 <br />pate of Exam <br />M I D I Y <br />M iRecertilication L3 <br />Q F FoApwup E <br />.Address <br />City. State, Zip Code <br />Work Tel: () <br />Dri+rer License f lo. <br />Licaiae Gans <br />Slate df Issue <br />EA EIC <br />Hone Tel: { <br />L` B CID <br />17 Other <br />_ 2. <br />C1*11:111.11.1 [ORM <br />Driver compleles this section, but medical examiner is encouraged to discuss with driver. <br />Yes No <br />Yes No <br />Yes W <br />Ej J Any miimd inpry;n me lag s rexsr <br />© H rii?Wn*im, d% Wm a Mnes <br />Sezues, epiepsr <br />[! me�$ralion <br />C7O Eye dgpreers of imp&nod yisimer[6R cyrrecd�rs knsesl <br />EardsordW$Lk$$OfneanrgaWatarce <br />Near decease neO neck. ohm wdorascuiar caedlim <br />C medz0v <br />Lung disease. emGhysema, asthma, chronic hrdodllss <br />Kidney disease, dia a <br />� s <br />LWSV dlsea5a <br />; Dgesbve pnohkms <br />' Dawes oreleveied hknd srgar ca&dlad by. <br />0 diet <br />D ors <br />0 irkaWi' <br />Nervous 1111 Ner orpsyohiaincdisorders, e.g., severe depression <br />e B Fairnrg, dta ness <br />° .Jeep a l ,k <br />Wilk a5/9ep eayame S1BBprlle58. bLl <br />vronng <br />Mho � n <br />Nisgng ar he'd arm. W. ky, <br />finge "w <br />apnet bwryadisease <br />C <br />�I] He4dzS M(vairerap meM.'by saenPOgaar. <br />1111 medicatihn <br />[ bwWpan <br />w 1 L kef) El kue medrclAlon <br />Mir ar d�vease <br />shodness ur balo <br />❑ pLon or, of Oared cwscausress <br />Rz9�sr. wax dcvhd uae <br />J Fleawlk a �i boring drjg use <br />For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including <br />over- the - counter medications) used regularly or recently. <br />I certify that the above information is complete and tare. I understand that inaccurate, `alse or missing information may invalidate the examination and my <br />Medical Examiners Certikcate. <br />Driver's Signature,__ _ Dat <br />Medical Examiners Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of <br />medications, including over- the - counter medications, while driving. This discussion must be documented below- ) <br />CRIMINAL BACKGROUND CHECK CONSENT <br />04/25/16 PDFConvert. 1073 1. 1. Section 1- Driver Employee_Selection -_Copy Attachment 6umber 1 \n <br />F -9 Page 189 <br />