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Driver Name (first, middle, last, suffix) Date of Birth Driver License Number Sex M Street Address City F State Zip Home Phone ( Health History Yes Date of Exam ) Driver completes this section, but medical examiner is encouraged to discuss with driver. No Yes Yes No 1. Any illness or injury in last 5 years, or any surgery 2. Head/brain injuries, disorders or illness 3. Seizures, epilepsy Medication: 4. Eye disorders or impaired vision (except corrective lens) 5. Ear diso.

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