Medical Examination Report Form (Page 3 of 9) in pdf

Form MCSA-5875 (Revised: 12/09/2015)

OMB No. 2126-0006

Expiration Date: 8/31/2018

Last Name:

First Name:

Middle Initial:

DOB:

Exam Date:

TESTING

Pulse rate:

Pulse rhythm regular:

Height:

feet

inches Weight:

pounds

Yes

Blood Pressure

Urinalysis

Systolic

Diastolic

Sp. Gr.

Protein

Blood

Sugar

Sitting

Urinalysis is required.

Numerical readings

Second reading

must be recorded.

(optional)

Protein, blood, or sugar in the urine may be an indication for further testing to

Other testing if indicated

rule out any underlying medical problem.

Vision

Hearing

Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. At

Standard: Must first perceive whispered voice at not less than 5 feet OR average

least 70° field of vision in horizontal meridian measured in each eye. The use of cor-

hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid).

rective lenses should be noted on the Medical Examiner's Certificate.

Check if hearing aid used for test:

Right Ear

Left Ear

Neither

Acuity

Uncorrected

Corrected

Horizontal Field of Vision

Whisper Test Results

Right Ear Left Ear

Right Eye:

20/

Right Eye:

degrees

Record distance (in feet) from driver at which a forced

Left Eye:

20/

Left Eye:

degrees

whispered voice can first be heard

Both Eyes:

20/

Yes No

Applicant can recognize and distinguish among traffic control

Audiometric Test Results

signals and devices showing red, green, and amber colors

Right Ear

Left Ear

Monocular vision

500 Hz

1000 Hz

2000 Hz

500 Hz

1000 Hz

2000 Hz

Referred to ophthalmologist or optometrist?

Received documentation from ophthalmologist or optometrist?

Average (right):

Average (left):

PHYSICAL EXAMINATION

The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or

is readily amenable to treatment. Even if a condition does not disqualify a driver, the Medical Examiner may consider deferring the driver temporarily.

Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible, particularly if neglecting the condition could

result in a more serious illness that might affect driving.

Check the body systems for abnormalities.

Body System

Normal Abnormal

1. General

8. Abdomen

2. Skin

9. Genito-urinary system including hernias

3. Eyes

10. Back/Spine

4. Ears

11. Extremities/joints