Delaware School Bus Driver Physical Examination Template printable pdf download

DELAWARE SCHOOL BUS DRIVER PHYSICAL EXAMINATION

Date: __________________

Annual Physical

First Time Physical (Tuberculin Test Required)

Print Name:

Last

First

M.I.

Driver License No.

State

Current Address:

Street

Social Security No.

Birth Date

(

)

City

State

Zip

Phone Number

MEDICAL HISTORY

Part I

(To be completed by applicant prior to physical examination)

Illness, Disability, Etc

Yes

If Yes, Give Diagnosis, Frequency, Extent and Severity

Date

Neurological condition

Seizure or other alteration of consciousness

Head or spinal injury or illness

Psychiatric disorder

Acute or chronic eye disease

Chronic lung or respiratory disease

Tuberculosis

Cardiovascular disease

High blood pressure

Gastrointestinal disorder

Diabetes

Asthma or other severe allergies

Impairment or limitation of use of limbs

Kidney disease

Present medications

Recent weight loss or weight gain

Other

I certify that all the above information is true and correct:

Applicant_______________________________ Physician Review__________________________

Part II

PHYSICAL EXAMINATION

The purpose of the physical examination is to detect the presence of physical and/or mental defects of such a character and extent as to affect the applicant’s ability

to safely perform the required duties of a school bus driver in normal and/or emergency circumstances. (The bus driver’s duties are listed on the next page.) Defects

may be recorded, which do not, because of their character or degree, indicate that a certificate of physical fitness be denied. The TB screening is required every 5

years.

General Appearance_________________________________________________________________

Height__________

Weight______________

VISION: (Distance) Right 20/______________Left 20/_____________

_______________________Without Glasses

____________________With Glasses

Color Vision ____________Horizontal Field of Vision_________ Right _______________ ° Left_______________ °

HEARING: (Twenty feet)

Right Ear________/20

Left Ear__________/20

Disease or Injury________________________________________