Nsw Medical Assessment Form Page 6

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Medical Assessment Form Public Passenger Vehicle Driver continued
36.
Cardiovascular System:
37. Neurological/Locomotor:
a.
a.
Blood Pressure (repeat if necessary)
Cervical Spine Rotation
Normal
Systolic
Systolic
Abnormal
give details
mm Hg
mm Hg
b.
Back movement
Normal
Abnormal
give details
Diastolic
Diastolic
c.
Upper Limbs
mm Hg
mm Hg
Muscle Strength
Normal
Abnormal
give details
b. Pulse Rate
Normal
Abnormal
give details
Co-ordination
Normal
Abnormal
give details
c. Heart Sounds
Normal
Joint movements
Normal
Abnormal
give details
Abnormal
give details
d. Peripheral Pulses
Normal
Reflexes
Normal
Abnormal
give details
Abnormal
give details
Note: if 'abnormal' selected for questions 36a - d please add
d. Lower Limbs
details below
Muscle Strength
Normal
Abnormal
give details
Co-ordination
Normal
Abnormal
give details
Joint movements
Normal
Abnormal
give details
Reflexes
Normal
Abnormal
give details
e. Romberg's Sign*
Normal
Abnormal
give details
* A pass requires the ability to maintain balance while
standing, shoes off, feet together side by side, eyes closed
and arms by sides, for 30 seconds.
Note: if 'abnormal' selected for questions 37a - e please add
details below
38.
Signs of alcohol and/or other drug abuse which may affect
the driver/applicant's ability to drive?
Present
Absent
continued page 7
Catalogue No. 45071751 Form No. 1689 (03/2016) ABN 76 236 371 088
Page 6 of 7

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