ddress City, State, Zip Code Work Tel: ( )
Driver License No.
License Class State of Issue
Home Tel: ( )
HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver.
Lung disease, emphysema, asthma, chronic bronchitis
Any illness or injury in the last 5 years?
Kidney disease, dialysis
Sleep disorders, pauses in breathing
Head/Brain injuries, disorders or illnesses
while asleep, daytime sleepiness, loud
Diabetes or elevated blood sugar controlled by:
Stroke or paralysis
Eye disorders or impaired vision (except corrective lenses)
Missing or impaired hand, arm, foot, leg,
Ear disorders, loss of hearing or balance
Heart disease or heart attack; other cardiovascular condition
Spinal injury or disease
Nervous or psychiatric disorders, e.g., severe depression
Chronic low back pain
Heart surgery (valve replacement/bypass, angioplasty,
Regular, frequent alcohol use
Loss of, or altered consciousness
High blood pressure medication___________________
Narcotic or habit forming drug use
Shortness of breath
For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including
over-the-counter medications) used regularly or recently.
I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my
Medical Examiner's Certificate.
Driver's Signature Date
Medical Examiner's Comments on Health History
(The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of
medications, including over-the-counter medications, while driving. This discussion must be documented below. )