ioetatacee amon Roe roe UAENNMEDA NNEC TEN TT ete cbr oa Sec Medical Examination Report Form ‘SECTION 1. Driver Information (tobe filed out by the diver) Lee Drivers License Number: 213881863460 Pail Issuing State/Province: FL Phone: (786) 918. E-mail opti CLP/CDL ApplicantiHolder: Q Yes @ No Driver 1D Veriied By: Driver's License. Has your USDOT/FMCSA medical certificate ever been denied or issued forlessthan 2 years? Yes @ No O Not Sure “Opa ac a Ge ee ore DRIVERHEALTH HISTORY Have you ever had surgery if-yes? please stand explain below. Over @No O Not Sure ‘Are you currently taking medications (orescription, If-yes: please describe below. ver-the-counte,herbalremedes, cit sypplerens)? Ores @No © Notsure (Attach adiional sheets fecessany) «-This document contains sensitive Information andor official use only. Improper handing of his information could negatively affect individuals. Hang and secre this internation aopropaatly o prevent inadvertent disclosure by Keeping the documents unde the contol of authorized pesons Properly dispose of hs document when fo longer quedo be maintained by regulatory requirements “* ev 32972002 Page!