Form 'C' - Medical Questionnaire Form
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1FORM ‘C’
[See Section 7 (3) and Section 12]
From of Medical Certificate in respect of an applicant for a Licence to drive any
transport Vehicle or to drive any Vehicle as paid Employee.
To be filled up by a Registered Medical Practitioner.
1)
What is the applicant’s apparent age?
______________________________
2)
Is the applicant, to the best of your
______________________________
judgment subject to epilepsy, vertigo
to any mental ailment likely to effect
his efficiency?
3)
Does the applicant suffer from any
______________________________
heart or lung disorder which might
interfere with the performance of his
duties as a driver?
4)
a)
Is there any defect of vision? If
______________________________
so, has it been corrected by
suitable spectacles?
b)
Does the applicant suffer from
______________________________
night blindness or colour
blinds?
c)
Does the applicant suffer from
______________________________
a degree of deafness which
would prevent his hearing
before ordinary sound signals?
5)
Has the applicant any deformity or
______________________________
loss of members which would
interfere with the efficient
performance of his duties as a driver?
6)
Does he show any evidence of being
______________________________
addicted to the excessive use of
alcohol, tobacco or drugs?
7)
Is he, in your opinion, generally fit as
______________________________
regards
a) Bodily heath, and b) eye-sight?
8)
Marks of identification?
______________________________
I certify that to the best of my knowledge and belief the applicant _____________
is the person herein above described and at the attached photographs is reasonably correct
likeness.
Signature
______________________________
Name
______________________________
Designation
______________________________
Note: Special attention should be direct to distant vision and to the condition of the arm
and hands and the joints of both extremities.
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