Medical Report


plantilla imagen principal
Haga clic en la imagen para ampliar

Guardar, completar los espacios en blanco, imprimir, listo!
How to create a Medical Report? Download this Medical Report template now!


Formatos de archivo disponibles:

.pdf


  • Este documento ha sido certificado por un profesionall
  • 100% personalizable


  
Calificación de la plantilla: 7

Malware en virus vrij: Norton safe website


Business Negocio Health Salud medical médico report informe driver conductor Information Información Test Report Informe de prueba Date Fecha Medical Report Sample Muestra de informe médico Medical Report Informe médico Medical Report Example Ejemplo de informe médico Examiner Examinador

How to write a Medical Report? Download this Medical Report template that will perfectly suit your needs.

Our collection of online health templates aims to make life easier for you. Our site is updated every day with new health and healthcare templates. By providing you this health Medical Report template, we hope you can save precious time, cost and efforts and it will help you to reach the next level of success in your life, studies or work!

Right Ear Left Ear Neither Acuity Uncorrected Corrected Horizontal Field of Vision Check if hearing aid used for test: Right Ear Left Ear Whisper Test Results Right Eye: 20/ 20/ Right Eye: degrees Record distance (in feet) from driver at which a forced 20/ 20/ Left Eye: degrees whispered voice can first be heard Left Eye: Both Eyes: 20/ 20/ Yes No OR Applicant can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors Audiometric Test Results Right Ear Left Ear Monocular vision 500 Hz 500 Hz 1000 Hz 2000 Hz 1000 Hz 2000 Hz Referred to ophthalmologist or optometrist Received documentation from ophthalmologist or optometrist Average (right): Average (left): PHYSICAL EXAMINATION The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or is readily amenable to treatment.. 2126-0006 First Name: Middle Initial: DOB: Expiration Date: 8/31/2018 Exam Date: Please complete only one of the following (Federal or State) Medical Examiner Determination sections: MEDICAL EXAMINER DETERMINATION (Federal) Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49): Does not meet standards (specify reason): Meets standards in 49 CFR 391.41 qualifies for 2-year certificate Meets standards, but periodic monitoring required (specify reason): Driver qualified for: 3 months Wearing corrective lenses 6 months 1 year other (specify): Wearing hearing aid Accompanied by a waiver/exemption (specify type): Accompanied by a Skill Performance Evaluation (SPE) Certificate Qualified by operation of 49 CFR 391.64 (Federal) Driving within an exempt intracity zone (see 49 CFR 391.62) (Federal) Determination pending (specify reason): Return to medical exam office for follow-up on (must be 45 days or less): Medical Examination Report amended (specify reason): (if amended) Medical Exam

This Medical Report is intuitive, ready-to-use and structured in a smart way. Try it now and let this Medical Report sample inspire you.

We certainly encourage you to download this Medical Report now and use it to your advantage!


Also interested in other health and healthcare templates? AllBusinessTemplates is the most elaborate platform for downloading health templates and is updated every day with new health and healthcare related templates! Just search via our search bar or browse through our thousands of free and premium health forms and templates, contract, documents, letters, which are used by professionals in the healthcare industry. For example health care directive, mental health treatment plan, health management report, allergy log, healthy weekly meal plans, sick leave letter, health evaluation form, and much more...


DESCARGO DE RESPONSABILIDAD
Nada en este sitio se considerará asesoramiento legal y no se establece una relación abogado-cliente.


Deja una respuesta. Si tiene preguntas o comentarios, puede colocarlos a continuación.


default user img

Plantillas relacionadas


Plantillas más recientes


Temas más recientes


Lee mas