Federal Register - July 7, 2021
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Source: Federal Register
35646
Federal Register / Vol. 86, No. 127 / Wednesday, July 7, 2021 / Rules and Regulations
1634
I
l.aSt llane: - - - - - - - - - - FirstName: - - - - - - - OOS: _ _ _ _ _ _ ExamDate: _ _ _ _ _ _ _
j
TESTING
Pro:teln
Systolic:
!JI@
Sittill9
S:ecohd reai:ling optional
Urinalysis is requlnad.
Numetical difg$
must be recqrded.
othertesing 1f illdlca,ed
Protein, blood, orsuffelri/1 tlie urine may be art iH!/ieatiOI.fQrliJrthertest/ng to rule rot anyundeliyinv medicafpOo/em.
Vililoti
flearlng
Standi:Ird1sailast<20/40acuity /5nellen.ineacheyewlth orwithootcorrectiM
0
i;tleast7QP/ielifofvisitsn ilJ /:rbr/Z.IJntame,iclian measu/ed.ini.,a.th;eye. The user;,
SiandardiMilsttirstperceive whlspereitvo/ceat nottessthan SfeetCIR averqge /rearing loss ofless,han or equalt041d8, ilJbettetecrr fw/tl! orwitnrut hearillg a.id,
r;orrectiveknses should be notedon the Medical /?xaminei:s. Certificate.
Acutty-
Uhcomected
Corrected
Horizontal Freid ofVision
Chec!
Right Eye:
20/_ _
10_ _
light Eye:: _ _ d8Qti!es
Wf!ispetl.utReiiults
haft Ey
201_.-
20/_ _
LeffEye: _ _ degrees
SothEyesc:
lQ/ _ _
20/_ _
0
Neither
Right Ear eftEar
lleco .dist11nc<1 inJe frg,:n dri atwhkh a for<;eq whil,pered voice can firstbeheattl
Yes 11,10
OR
Appllcantcan recognl:ze and distlrfgulsh amongtraffkcontro!
signals and devlce,sshowing red, green, and amber cqlor
00
Mona ular v:fslpn
00
:Aui!lolbetriTestlleslllts Right Eat:
SOOHz iOOOHz iOOOHz
S:OOH
Referred loophthallt!Ol
00
Average right: _ _ _ _ __
Average li!ft: _ _ _ _ __
00
eftl;at;
lllQO:Hz
.2000 Hz
PHYSICAL EXAMINATION
ihepresencenfa certaincondition:maynotnecessarily disqualify a driver,particularlyiftheconditlon is<:ontrolled adequat;;ly, is not likelytti worh, ilr ;sreadily amenablEto treatmen.t,Even if a <:onc!1tion:d 11ot c1 isqulify a dri.v-er, the Med ital Exa 1111 ner m;,y consider dafei:t1n9 the cttiver temp<1rarily. Also.thediivershould be aclyised totallethe necessary steps to correct the condition as soon as,possil:!le,partlaularly if neglecting the QnditlOI cou Id resu It .in a 1110,e serious ill nes.s that might affect drNin-g.
:Check the.body systemsfqrabnormalities.
Normal Al:inoritial
Body swtei!I
0
0
1.General 2,Skin
80
3.Eyes 4.l;?IS
S:.Mouth/throat 6. tardlovas<:ular
0
0
0
Nc,:rrnal Af:ihormI
0
10.. Batl
12, Nurologlcal system Including reflexes tl.Gait 14. Vi!SCU Tar system
0
0
0
i!.Alldomen Qc. Genifo-urlnarysystem inducllng hernias:
0
0
0
0
0
0
7.Lungs/chest 0
0
Discuss any abnormal answers in detailin thespace below and indicate whether it wou!daffet:t the drivers ability to operate a CM,.
0
0
0
0
0
0
0
Enterapplicableiteir number befofe:each comment.
Attach additional sheets ifnecessary
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