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DRIVER'S LICENSE NUMBER CASE NUMBER <br /> Class Restriction Driver's name Age Tel number <br /> Occupation Reason for medical report <br /> 1. MEDICAL HISTORY-Complete all items. <br /> Yes No <br /> ❑ ❑ A. Does your patient have a physical, neurological, or mental impairment that might impair safe <br /> driving? <br /> B. What is the diagnosis of your patient's illness or injury? <br /> C. How long have you treated this patient? <br /> When was the most recent visit? <br /> D. What medication(s)is the patient taking?Name drugs. How often? <br /> DRUG DOSE SCHEDULE <br /> 11. MEDICAL CONDITIONS-Complete problem areas only. <br /> Yes No <br /> ❑ ❑ A. CARDIAC/PULMONARY- Initial if not applicable and skip this section. <br /> 1. Vital signs: BP P RR <br /> ❑ ❑ Edema? <br /> ❑ ❑ Supplemental oxygen needed? <br /> ❑ ❑ 2. Does patient have chest pain(angina)or obvious dyspnea? <br /> If yes,describe for"at rest", "slight exertion", or"moderate." <br /> ❑ ❑ 3. Does patient have any of the following: syncope, vertigo, infarction? <br /> If yes, give details. <br /> ❑ ❑ 4. Does patient take medication regularly for cardiovascular condition? <br /> If yes, explain. <br /> 5. Describe any cardiac assistive device, e.g. pacemaker, and give implant date. <br /> 6. Describe patient's functional capacity(AMA): <br /> Class 1 No limitation physical activity <br /> Class 2 Slight limitation physical activity <br /> Class 3 Marked limitation physical activity <br /> Class 4 Complete limitation physical activity <br /> Medical Report-DOT-H 2058(4/09) Page 1 of 4 <br />