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.

Medical Report (MED 2), prior to the effective date noted in the Notice/Order to avoid having your driving privilege suspended. ... DMV received a crash report, Medical Review Request Form, or a court document that requires a medical evaluation. Please refer to the customer explanation letter that describes the issue of concern that needs to be

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