New Hampshire requires driver education instructor applicants to pass a physical recorded on this one-page form, whose stated purpose is to detect physical defects that would affect their ability to safely teach driver education. The physician records vision, hearing and reflexes, notes any illness, surgery or medication from the past five years, and signs the Licensed Physician's Certificate.
The applicant enters their name, date of birth and address. A licensed physician completes the examination findings, the medical history and the Licensed Physician's Certificate, adding license number, issuing state and expiration date.
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Driver Education Instructor Physical Form
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A licensed physician, who certifies being familiar with the applicant's present medical condition and that the applicant is physically capable of instructing driver education. The physician adds name, title, license number, the issuing state and its expiration date, and signs the Licensed Physician's Certificate.
Any illness, surgery or prescription medication in the past five years, including diabetes, rheumatic fever, psychiatric or nervous disorders, tuberculosis, ulcers, cardiovascular disease, seizures or fainting, asthma, muscular disease, kidney disease, head or spinal injuries and permanent defects. The physician explains any item that applies.