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Date M/D/Y Address City, State, Zip Code Work Tel: ( ) Age New Certification Sex M Recertification F Follow-up Driver License No. License Class A B Home Tel: ( ) 2. HEALTH HISTORY Date of Exam State of Issue C D Other Driver completes this section, but medical examiner is encouraged to discuss with driver. Yes No Yes No Yes No Any illness or injury in the last 5 years? Head/Brain injuries, disorders or illnesses Seizures, epilepsy medication Eye disor.

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