This is not the official DMV Medical Examination Report, it was

/I.Jf
A Public Service Agency
051
MEDICAL EXAMINATION REPORT
FOR COMMERCIAL DRIVER FITNESS DETERMINATION
1. DRIVIER INFORMATM;)N Qriver completes thla HQUon. PRINT IN CAPITAL LETTERS · USING BLACK ot:t DARK BLUE INK.
DRIVER LICENSE NUMBER
FIRST
LAST NA ME
t, po
l
r
a
o
i ep
r
c
u
i
f
p
f DR n D
I
D e o
n tio
Ds De
IDA
o
i
h
t DF at eta
tDM
o
in rpI r
n
m
PLEASE READ THE "INSTRUCTIONS
TO
THE
DRIVER"
BEFOREANSWERING.
s xa
i
e
t
s
n
E
i
i
Dh
T ical for
0
ed IMG
M
y
V
b
M
d
D te
a
FOLWWING INFORMATION
e
r
c
s
a
w
M.USI
t
i
STATE
CITY
ADDRESS
SOCIAL SECURITY NUMBER
LICENSE CLASS
,
ZIP
STATE OF ISSUE
New certification
SEX
AGE
BIRTH DATE
.
s
se
Recertification
Follow up
EYES
MARK ONE OF THE DRIVING TYPES BELOW
0
D
Nl
Non-Excepted Interstate
El
Excepted Interstate (Not available in California)
NA
Non-Excepted Intrastate
EA
Excepted Intrastate (Not available in California)
CHECK ONE OF THE BOXES BELOW
0
0
1 am NOI. submitting this medical examination report to obtain a certificate to operate a School Bus, School Pupil Activity Bus, Youth Bus,
General Public Paratransit Vehicle, or Farm Labor Vehicle.
�submitting this medical examination report to apply for or retain a certificate to operate a School Bus, School Pupil Activity Bus, Youth
Bus, General Public Paratransit Vehicle, or Farm Labor Vehicle.
PLEASE READ THE
If you indicated you have submitted this medical examination report for one or more of the certificates listed above, your medical examination
a Physician Assistant, Advanced Practice Registered Nurse, Doctor of Medicine (MD), Doctor of Osteopathy (DO), or a
Doctor of Chiropractic (Chiropractor) listed on the most current National Registry of Certified Medical Examiners. Your medical examination report
and medical certificate
be signed by the physician who performed the examination. If your medical examination report does not indicate
your medical examination was performed by an MD, DO, Physician Assistant, Advanced Practice Registered Nurse or a Chiropractor listed on
the most current National Registry of Certified Medical Examiners; D MV will not process your certificate application or accept your medical
examination report, and your medical examination report will be returned to you.
M..1J.SI be performed by
2. HEALTH HISTORY
Driver completes ttlla aectlon• .,_ medical examiner Ia encouraged to dlacua with driver.
Yes No
Yes No
enfermedad
o lastimadura
enyears
los últimos 5 años DD Shortness
Dificultad paraofrespirar
DDAlguna
Any illness
or injury
in last 5
breath
Enfermedades
pulmonares,
enfisema,
asma,
o lastimaduras
de la cabeza/cerebro
DDEnfermedades
Head/Brain injuries,
disorders
or illnesses
DD Lung
disease,
emphysema,
asthma,
bronquitis
crónica
DD Convulsiones/ataques,
Seizures, epilepsy epilepsia
chronic bronchitis
Enfermedades
del riñón, diálisis
D Medicación
medication
DD Kidney
disease, dialysis
Enfermedades
del hígado
de or
los impaired
ojos o dificultad
D
D
Liver
disease
DD Enfermedades
Eye disorders
vision (except
para ver (excepto cuando usa lentes)
Problemas digestivos
corrective lenses)
D D Digestive
problems
Diabetes o azúcar
alta en la
sangresugar
de los
oídos,
pérdida del
o balance DD Diabetes
or elevated
blood
D DEnfermedades
Ear disorders,
loss
of hearing
oroído
balance
controlada con:
del or
corazón
controlled by:
D D Enfermedades
Heart disease
hearto ataque
attack,alother
corazón, otra condición cardiovascular
DDieta
diet
cardiovascular condition
D Píldoras
pills
D Medicación
medication
corazón(valve
(reemplazo
de
DInsulina
insulin
D D Cirugía
Heart del
surgery
replacement/
válvula, bypass/derivación, angioplastía, marcapaso)
bypass, angioplasty, pacemaker)
Presión
arterialpressure
alta
High blood
DD
DMedicación
medication
musculares
D D Enfermedades
Muscular disease
nerviosas o psiquiátricas,
D D Enfermedades
Nervous or psychiatric
disorders,
por
ejemplo
depresión
severa
e.g.,
severe
depression
Medicación
medication
Yes No
mareos
DDDesmayos,
Fainting, dizziness
del sueño,
pausas in
al respirar
DDDesórdenes
Sleep disorders,
pauses
breathing
cuando duerme, somnolencia durante el día,
while asleep, daytime sleepiness, loud
rónquidos fuertes
snoring
Ataque
o parálisis
Strokecerebral
or paralysis
DD
o deterioro
de función
de la mano,
brazo,leg,
DDFalta
Missing
or impaired
hand,
arm, foot,
pie, pierna, dedo de la mano o del pie
finger, toe
o enfermedad
de la columna vertebral
DD Lastimadura
Spinal injury
or disease
Dolor de espalda
baja pain
crónico
DD Chronic
low back
Uso regularfrequent
o frecuentealcohol
del alcohol
DD Regular,
use
o uso
de narcóticos
o drogas
DD Hábito
Narcotic
orformado
habit forming
drug
use
·
D
o alteración
de la
consciencia
DDPérdida
Loss of,
or altered
consciousness
_________
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. (Attach additional sheet, if needed).
I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's
Certification.
DRIVER"S SIGNATURE
L.::
X
REV.
11/2014)
Page 1 of 4