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/D/Y Address City, State, Zip Code Work Tel: ( ) Home Tel: ( ) Age New certification Date of Exam Recertification Follow Up License Class State of Issue Driver License No. A C Sex M F B 2. HEALTH HISTORY 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 last 5 years? Lung disease, emphysema, asthma, chronic bronchitis Fainting, dizziness Head/Brain injuries, disorders or illnesses K.

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