Transcription of STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY …
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STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY …
HSMV 72423 (Effective 07/18), , , , , , Page 1 of 4 STATE OF FLORIDA DEPARTMENT OF HIGHWAY SAFETY AND MOTOR VEHICLES MEDICAL REPORT INSTRUCTIONS TO THE DRIVER: Please take this form to the physician most familiar with your medical history and the current status of your medical condition(s). Name: _____ Driver License #:_____ Date of Birth: _____ Telephone #:_____ INSTRUCTIONS TO THE PHYSICIAN: Please complete this form in its entirety. If a section does not apply, indicate not applicable or N/A . HISTORY: 1. How long have you known this patient? _____ Date of last office visit? _____ 2. Other physicians the patient has seen in the past 2 years: _____ 3. List any medical conditions or physical impairments the patient has: _____ _____ 4. List all prescribed medications: _____ _____ 5. Does the patient receive regular medical care? _____ Is patient reliable in taking medications?
STATE OF FLORIDA . DEPARTMENT OF HIGHWAY SAFETY . AND MOTOR VEHICLES . MEDICAL REPORT . INSTRUCTIONS TO THE DRIVER: Please take this form to the physician most familiar with your medical history and the current status of your medical condition(s).
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