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Fillable Printable Physical Examination Report

Fillable Printable Physical Examination Report

Physical Examination Report

Physical Examination Report

SBTS-602
SBTS-602 (Rev. 2/00)
North Carolina Division of Motor
Vehicles
PHYSICAL
EXAMINATION REPORT
Required of all persons upon initial employment as a
Commercial Driver Training School Instructor
1.
Name:
2. Age:
3. Sex:Male Female
4. Address:
5. Blood Pressure:
6. Weight:
7. Height:
8. Skin: (Record any evidence of disease)
9. Vision:
Without glasses
R: 20/
L: 20/
With glasses
R: 20/
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SBTS-602
L: 20/
10. Hearing: Is there any obvious hearing disorder?
Yes No
If yes, please describe:
11. MOUTH,NOSE,THROAT: (Record any evidence of disease or presence of speech
defect)
12. HEART AND LUNGS:
(State whether individual can undergo normal activity)
13. TUBERCULOSIS: Tuberculin skin test: (Record date and findings)
14. IMMUNIZATION: Has individual been immunized against
tetanus/diphtheria with adult-type tetanus/diphtheria (Td) toxoids
within past ten years?
Yes No
Rubella: Immunization
Yes No
Blood Test indicating immunity
Yes No
15. ABDOMEN: (Record any abnormality found, including hernia)
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SBTS-602
16. GENITO-URINARY: (Record any abnormalities found, result of
urinalysis, and if necessary microscopic examination of discharge)
17. NERVOUS AND MENTAL: (Record any defects found)
18. ADDITIONAL FINDINGS:
19. RECOMMENDATIONS:
This is to certify that an examination of the above-named person shows the results
indicated, and that is (not) free of tuberculosis or other communicable disease,
or any disease, physical or mental, which will impair the ability of said person to perform his or
her duties as a commercial driving training school instructor.
Date:
Signature of Physician: _______________________________
M.D.
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