Transcription of CUSTOMER MEDICAL REPORT - Virginia
{{id}} {{{paragraph}}}
Example: barber
CUSTOMER MEDICAL REPORT - Virginia
MED 2 (11/25/2020) CUSTOMER MEDICAL REPORTD escribe, in detail, your MEDICAL condition. WEIGHT HEIGHT FTINlbsBIRTH DATE (mm/dd/yyyy) Do you take prescription/non-prescription medications? If Yes, list below. (attach a separate sheet if more space is required) YESNONON-PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN PRESCRIPTION MEDICATION DOSAGE TIME(S) TAKEN Have you ever experienced a blackout, seizure, loss of consciousness, or syncope? If Yes, enter date of last the episode result in a motor vehicle crash?YESNODATE (mm/dd/yyyy) YESNOE xplain what happened during the episode.
level of consciousness/alertness vision/perception motor skills/range of motion judgment/cognitive function reaction time 2. DMV may have requested these documents for one of three reasons: DMV received a crash report, Medical Review Request Form, or a court document that requires a medical evaluation.
Tags:
Information
Domain:
Source:
Link to this page:
Please notify us if you found a problem with this document: