Nsw Medical Assessment Form Page 5

Download a blank fillable Nsw Medical Assessment Form in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Nsw Medical Assessment Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

Medical Assessment Form Public Passenger Vehicle Driver continued
31.
Height (metres)
Weight (kilos)
Body Mass Index
Part E – Medical Practitioner Details – to be
2
completed by your usual Medical Practitioner (General
Kgs
divided
m
=
Practitioner or Family Doctor) ONLY
Weight: BMI - see Sleep Disorders on page 106 of the
20.
Medical Practitioner name (please print)
publication 'Assessing Fitness to Drive' March 2012.
32.
Vision
Visual acuity
Right
Left
a.
21.
AHPRA number
Uncorrected
6/__________
6/__________
Corrected
6/__________
6/__________
22.
Practice address (PO box not accepted)
b.
Are corrective lenses worn?
Yes
No
Postcode
0
c.
Binocular visual field should have an extent of at least 140
23.
Telephone number
0
within 10
above and below the horizontal midline. Is this
standard met?
Yes
No
24.
Fax number
33.
Urinalysis
Normal
25. Email
Abnormal
give details
34.
Abdomen
Normal
26.
Examination date
Abnormal
give details
/
/
day
month
year
Note: if 'abnormal' selected for questions 28 - 34 please add
details below
27. GP stamp
Part F – Clinical Examination – to be completed by
your usual Medical Practitioner (General Practitioner or
Family Doctor) ONLY
(refer to AFTD website )
28.
Head, neck and throat appearance
Normal
Abnormal
give details
29.
Chest /Lungs
Clear
Abnormal
give details
30.
Hearing
a.
without a hearing aid
Left
Right
35.
Is Neuropsychological Assessment required (e.g. in case of
Normal
Normal
head injury)?
Abnormal
Abnormal
Yes
No
with a hearing aid
b.
Normal
Abnormal
give details
continued page 6
N/a
Catalogue No. 45071751 Form No. 1689 (03/2016) ABN 76 236 371 088
Page 5 of 7

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Medical Assessment Form For Fitness To Dive Medical Assessment Form For Fitness To Dive Legal
Medical Specialist Assessment Form - Public Passenger Vehicle Driver - Roads And Maritime Services Medical Specialist Assessment Form - Public Passenger Vehicle Driver - Roads And Maritime Services Medical
Medical History And Pain Assessment Form Medical History And Pain Assessment Form Medical
Form Aw-1.01837 - Prescription / Certificate Of Medical Necessity / Risk Assessment Form Form Aw-1.01837 - Prescription / Certificate Of Medical Necessity / Risk Assessment Form Business
Medical Assessment For Drivers With Insulin-treated Diabetes - Nova Scotia Medical Assessment For Drivers With Insulin-treated Diabetes - Nova Scotia Legal
Medical History Form - Oregon Medical Group Medical History Form - Oregon Medical Group Medical
Form-3 - M.e.a. Medical Department Cadet Pilots Medical Screening Form Form-3 - M.e.a. Medical Department Cadet Pilots Medical Screening Form Medical
Medical Claim Form (medical/dental/vision) Medical Claim Form (medical/dental/vision) Legal
Form Gc-10 (2-12) - Vision Benefits Medical Claim Form And Medical Benefits Request Form- Aetna Form Gc-10 (2-12) - Vision Benefits Medical Claim Form And Medical Benefits Request Form- Aetna Business
Medical And Physical Condition Standard Information And Medical Release Form Medical And Physical Condition Standard Information And Medical Release Form Legal

Related Categories

Parent category: Medical
Download
Go
Page of 7