Book contains your regular creasing from use and reading… But cover is still intact. Inside pages are all still intact. However, a many of them have underlining and notes in the margins… Not mine actually. I will say a lot of of the review pages with questions do have the answer circled! But it otherwise provides all the information needed and is not missing anything. If you are taking a general class and need the manual to prepare, this book definitely works great! And you will probably be provided the book in class as well to use as you complete the test. It is the 2020 American Heart Association version provider manual.