Cdl Physical Examination Form printable pdf download

Louisiana Department of Public Safety & Corrections

Office of Motor Vehicles

CDL PHYSICAL EXAMINATION FORM

(Meets Department of Transportation Requirements)

Date of Examination: _____________

New Certification

Re-certification

Follow up

1. DRIVER’S INFORMATION: Driver completes this section.

Driver’s Name: ______________________________________________________________________________________________________

Address: ___________________________________________________________________________________________________________

Soc. Sec. No. ___________________________________ Date of Birth _____________________ Age ___________ Race/Sex ____________

Driver’s License No. _______________________ Class ______ State ______ Telephone: ___________________________________________

2. HEALTH HISTORY: Driver completes this section, but medical examiner is encouraged to discuss with driver.

Yes No

Yes

Any illness or injury in last 5 years?

Diabetes or elevated blood sugar controlled by:

Head/Brain injuries, disorders or illnesses

diet

Seizures, epilepsy

pills

If yes, specify medication ____________________________

insulin

Eye disorders or impaired vision (except corrective lenses)

Nervous or psychiatric disorders, severe depression

Ear disorders, loss of hearing or balance

If yes, specify medication _____________________________

Heart disease or heart attack; other cardiovascular condition

Loss of or altered consciousness

If yes, specify medication ____________________________

Fainting, dizziness

Heart surgery (valve replacement/bypass, angioplasty,

Sleep disorders, pauses in breathing while asleep,

pacemaker)

daytime sleepiness, loud snoring

High blood pressure

Stroke or paralysis

If yes, specify medication ___________________________

Muscular disease

Missing or impaired hand, arm, foot, leg, finger or toe

Shortness of breath

Spinal injury or disease

Lung disease, emphysema, asthma, chronic bronchitis

Chronic low back pain

Kidney disease, dialysis

Regular, frequent alcohol use

Liver disease

Narcotic or habit forming drug use

Digestive problems

For any YES answer, indicate onset date, diagnosis, treating physician’s name and address, and any current limitations. List all medications

(including over the counter medications) used regularly or recently.

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination

and my Medical Examiner’s Certificate.

Driver’s Signature

Date

Medical Examiners’s Comments on Health History (The medical examiner must review and discuss with the driver any YES answers and

potential hazards of medications including over-the-counter medications while driving. Should additional medical documentation from a treating

physician be warranted prior to determining if the driver meets the minimum requirements, said documentation should become a part of his/her

medical file which is maintained in your office.) Discussion with driver should be documented below.

Is the condition(s) likely to hamper the driver’s ability to control and/or safely operate a commercial motor vehicle?

Yes

Does treatment/medication utilized cause any side affects that are likely to hamper the ability to control and/or safely operate a commercial motor

vehicle?

Yes

Cdl Physical Examination Form

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