Checkup For Pdvl - Medical
You can copy and paste this template into a word processor or present it to a licensed clinic. To be completed by a Registered Medical Practitioner 1. PERSONAL INFORMATION | Field | Details | | :--- | :--- | | Full Name | [Last Name, First Name] | | NRIC / FIN No. | [S1234567A / G1234567X] | | Date of Birth (DD/MM/YYYY) | [01/01/1980] | | Gender | [ ] Male [ ] Female | | Contact Number | [9123 4567] | | Driving Experience (Years) | [e.g., 10 years] | 2. MEDICAL HISTORY (To be completed by applicant & verified by doctor) Does the applicant have a history of any of the following? (Please tick)
| Condition | Yes | No | Remarks (if Yes) | | :--- | :---: | :---: | :--- | | Epilepsy / Seizures | ☐ | ☐ | | | Diabetes Mellitus (on insulin) | ☐ | ☐ | | | Heart Disease (e.g., arrhythmia, ICD) | ☐ | ☐ | | | Stroke / TIA | ☐ | ☐ | | | Sleep Apnoea / Narcolepsy | ☐ | ☐ | | | Severe psychiatric disorder | ☐ | ☐ | | | Alcohol / Substance dependence | ☐ | ☐ | | | Visual impairment (even with glasses) | ☐ | ☐ | | | Hearing impairment | ☐ | ☐ | | | Any other chronic illness | ☐ | ☐ | | | Parameter | Measurement | Normal Range | Remarks | | :--- | :--- | :--- | :--- | | Blood Pressure (sitting) | ___ / ___ mmHg | <140/90 | | | Pulse Rate | ___ bpm | 60-100 | | | Body Mass Index (BMI) | ___ kg/m² | 18.5-24.9 | | | Visual Acuity (with/without aids) | Right: ___ / ___ | At least 6/12 | | | | Left: ___ / ___ | At least 6/12 | | | Binocular Vision | 6/ ___ | 6/12 or better | | | Colour Vision | [ ] Normal [ ] Deficient | Ishihara test | | | Visual Field | [ ] Normal [ ] Defect | Confrontation method | | | Hearing (Whisper test / Audiometry) | [ ] Pass [ ] Fail | Hear 3m whisper | | 4. ADDITIONAL TESTS (if indicated) | Test | Result | Date Done | | :--- | :--- | :--- | | Random / Fasting Blood Glucose | ______ mmol/L | | | HbA1c | ______ % | | | Resting ECG | [ ] Normal [ ] Abnormal | | | Urinalysis for glucose / ketones | [ ] Negative [ ] Positive | | 5. CURRENT MEDICATIONS | Medication Name | Dose | Frequency | Reason | | :--- | :--- | :--- | :--- | | e.g., Metformin | 500mg | Twice daily | Diabetes | | | | | | 6. DOCTOR’S ASSESSMENT OF FITNESS TO DRIVE (Please tick one) medical checkup for pdvl
☐ – Reason: ________________________________________ 7. DECLARATION Applicant’s Declaration: I declare that the information given above is true and complete. I consent to this report being submitted to the relevant licensing authority. You can copy and paste this template into
I have examined the above-named person and certify that, to the best of my knowledge, the findings are accurate. I have explained any restrictions or treatments required. | [S1234567A / G1234567X] | | Date of
Signature of Applicant: ________________________ Date: ____________
