Free 03337.FH11 - Indiana

PART A - MEDICAL CERTIFICATION - PUBLIC PASSENGER CHAUFFEUR LICENSE
State Form 3337 (R4 / 3-04)

PHYSICIAN NOTE: Part A to be retained on file in your office for at least two years. Part B to be completed and given to examinee.
Name of examinee Social Security number Address (number, street, city, state and ZIP code) Age Date of birth Sex

This state agency is requesting disclosure of Social Security number that is necessary to accomplish the statutory purpose of this state agency according to IC 4-1-8. Disclosure of this information is voluntary, you have the right to refuse to provide this information and will not be penalized therefor.

HISTORY (To be filled out by examinee in full) YES NO 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Are you taking any medications of any type? Are you under a doctors care for any medical condition or physical disorder? Have you been hospitalized for anything? Do you have or have you ever had any serious illnesses or injuries? Do you have any physical impairments or impairment of vision or hearing? Do you have or have you ever had a seizure disorder, epilepsy, blackout spells, fainting spells, lapses of consciousness, or severe dizzy spells? Do you drink alcohol excessively or use illicit drugs? Do you have any contagious diseases or illnesses? Have you ever had tuberculosis or a positive T.B. skin test? Have you ever experienced or do you presently experience chest pain, pressure, or discomfort when exerting yourself?

If yes to any of these questions, explain: NOTICE: Physical examination certificate signed and issued by a physician duly licensed by the State of Indiana required to be presented with application for Public Passenger Chauffeur License according to Chapter 304, Sections 55 and 56, Acts 1945. Height Weight Temperature Pulse B/P Skin Signature of examinee Date (month, day, year)

PHYSICAL EXAMINATION (To be filled out by physician)
Vision for distance (Acuity via either machine testing or Snellen Chart) Both Eyes Right Eye Left Eye Uncorrected 20/____________ 20/_____________ 20/_____________ Corrected 20/____________ 20/_____________ 20/_____________ Hearing (via either audiometry or whispered voice) Right Left Neck Heart Upper extremities ANCILLARY TESTS: Sugar__________________ Protein__________________ Additional findings/physicians comments: Signature of physician Date (month, day, year) Peripheral vasculature Lower extremities Tuberculosis skin test ** E.K.G. ** Abdomen Neurological Chest radiograph ** Other ancillary tests ** Satisfactory Unsatisfactory Satisfactory Unsatisfactory Thorax and lungs Genitalia/rectal **

General appearance/development H.E.E.N.T.

NOTE: ** IF INDICATED OR AS DEEMED NECESSARY BY EXAMINING PHYSICIAN

PART B - MEDICAL CERTIFICATION - PUBLIC PASSENGER CHAUFFEUR LICENSE
State Form 3337 (R4 / 3-04)

PART B ONLY - TO BE DETACHED AND GIVEN TO EXAMINEE TO TAKE TO LICENSE BRANCH. A copy of the physical examination is on file in the examining physicians office. On of
Date of examination (month, day, year)

, I personally examined
Address

Name of examinee

In my medical opinion this examinee did not have at the time of this examination any medical disorder or physical condition which was likely to interfere with his/her ability to safely operator a motor vehicle used to convey public passengers. In addition, did not have any significant active communicable disease at the time of his/her examination.
Name of physician Address (number, street, city, state, and ZIP code) Signature of physician Telephone number

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