Driver's Medical Form
YOU CAN SIMPLY WALK IN 7 DAYS A WEEK (9AM TO 7PM)
This form is to be filled out when you are actually in the building.
Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Smoker
Please Select
No
Yes
PPD
Alcohol Use
Please Select
No
Yes
Amount
Obesity
Please Select
No
Yes
High Blood Pressure
Please Select
No
Yes
Diabetes
Please Select
No
Yes
Medication and dosages are required
Doctor may request for proof o Diabetes Control
ON Insulin
Please Select
No
Yes
Leg Amputation/Prosthetic
Please Select
No
Yes
Or Finger, Toes, Arms
Please Select
No
Yes
Hearing Impairment
Please Select
No
Yes
(i.e. Hearing aid, Deafness, etc.)
Blind in One or Both Eye
Please Select
No
Yes
Glasses/Contacts for Driving
Please Select
No
Yes
Submit
Should be Empty: