This document is a form used by the Utah Driver License Division for medical evaluations of commercial drivers and non-commercial drivers. It includes sections for visual acuity, diabetes and metabolic conditions, cardiovascular conditions, pulmonary conditions, oxygen while driving, neurologic conditions, seizures and episodic conditions, alcohol and other drugs, musculo-skeletal or chronic debility, alertness or sleep disorder, disorders or conditions not marked that are relevant to safe driving, health care professional comments, exam date, printed name of health care professional, signature & degree, state license number, form signed date, street address city state zip code, and telephone.
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