Free MV3030B Medical Examination Report - Wisconsin

PHYSICAL EXAMINATION REPORT
For S or P Endorsement
MV3030B 6/2007 Ch. 343 Wis. Stats.

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Wisconsin Department of Transportation Medical Review P O Box 7918 Madison, WI 53707-7918
Telephone: 608-266-2327; FAX: 608-267-0518 E-mail: [email protected] Operator License Number Birth Date Area Code - Telephone Number

Incomplete forms will be returned for completion.
Applicant Name Street Address City, State ZIP Code

Note: Pursuant to Trans 112, Wis. Admin. Rules (copy available upon request), this report is to be completed prior to consideration for licensing. The Secretary of the Department of Transportation is, by statute, responsible for the decision of driver's licensing. Any charges or fees for the medical examination and preparation of Section B is the resonsibility of the applicant (driver). Contact the Department of Public Instruction at 608-266-2146 regarding questions about the TB requirement.

Section A HEALTH: Applicant completes this section when applying/holding for P and S endorsement. YES NO YES NO Alcohol or other drug abuse or dependency controlled by treatment Blood pressure over 180/105 Alcohol or other drug abuse or dependency within the past 12 months Alcohol or other drug abuse or dependency within the past 12-24 months Diabetes or elevated blood sugar controlled by: Diet Pills Insulin Kidney disease, dialysis Mental/Emotional Functions Missing or impaired hand, arm, foot, leg Positive TB in a communicable form Required oxygen use Loss of, or altered consciousness Date _______________ Seizures, epilepsy Episode Date _______________

Heart disease or heart attack, stroke, other cardiovascular condition Lung disease, emphysema, asthma, chronic bronchitis Neuro/Muscular disease, e.g., ALS, MS, Head Trauma Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring Heart surgery (Valve replacement/bypass, angioplasty, pacemaker, AICD) Date _______________

For any YES answers, indicate onset date, diagnosis and any current limitations. List all medications (including over-the-counter medications) used regularly or recently.

I certify that the answers and statements made on this report are true and correct. I authorize the examining physician to release full details of an examination upon request to my employer, the School Board and the Wisconsin Department of Transportation.

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Section B
ACUITY Right Eye Left Eye Numerical readings must be provided. REQUIRED
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(Applicant Signature)

(Date)

HEALTH: Health Care Professional completes this section for applicant applying/holding for S endorsement.
UNCORRECTED CORRECTED TEMPORAL FIELD OF VISION IN 20/ 20/ 20/ 20/ Right Eye Left Eye Can the applicant recognize and distinguish amoung traffic control signals and devices showing standard red, green and amber colors? Yes No Are corrective lenses required when driving? Yes No Examining Authority Signature & Medical License No. (If different from below)

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YES NO Blood pressure over 180/105 Kidney disease, dialysis Mental/Emotional Functions Insulin Missing or impaired hand, arm, foot, leg Positive TB in a communicable form Required oxygen use Loss of, or altered consciousness Date _______________ Seizures, epilepsy Episode Date _______________

YES NO Alcohol or other drug abuse or dependency controlled by treatment Alcohol or other drug abuse or dependency within the past 12 months Alcohol or other drug abuse or dependency within the past 12-24 months Diabetes or elevated blood sugar controlled by: Diet Pills Heart disease or heart attack, stroke, other cardiovascular condition Inability to hear with or without hearing aid, instruction given in normal conversational tone Lung disease, emphysema, asthma, chronic bronchitis Neuro/Muscular disease, e.g., ALS, MS, Head Trauma Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring Heart surgery (Valve replacement/bypass, angioplasty, pacemaker, AICD) Date _______________

For any YES answers, indicate onset date, diagnosis and any current limitations. List all medications (including over-the-counter medications) used regularly or recently.

This report must be based on an examination conducted within the past 90 days. I certify that I have examined this applicant and that I am licensed to practice _______________________________ (MD, DO, PA, DC, MSN, FNP, GNP, RN).
Print Name Authorized Signature Patient Examination Date: Month - Day - Year Medical License No. Area Code-Office Telephone No.

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