Pre-Owned Vehicle Test Drive Medical Disclosure Form
Date
Full Name
Phone Number
Email Address
Driver’s License Number
Medical Information
Do you currently have any medical conditions that may impair your ability to safely operate a motor vehicle?
No
Yes
If yes, please provide details
Are you currently taking any medication that may affect your ability to drive?
No
Yes
If yes, please provide details
Are you experiencing any of the following symptoms today? (Check all that apply)
Dizziness
Blurred Vision
Fatigue
Shortness of Breath
Other
If Other, please specify
Acknowledgement
I certify that the information provided above is accurate and complete to the best of my knowledge. I also acknowledge that I have disclosed any medical conditions or medications which may affect my ability to safely operate a motor vehicle during the test drive.
Signature of Test Driver
Date