Cdl Physical Examination Form Page 2
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8NAME: __________________________________________________
TESTING Medical examiner completes Section 3 through 7
3. VISION: Standard: At least 20/40 distance acuity (Snellen) in each eye with or without correction. At least 70 degree peripheral in
horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner’s Certification.
INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20
feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears
corrective lenses, these should be worn while visual acuity is being tested. If the driver habitually wears contact lenses or intends to do so while
driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.
Numerical reading must be provided:
ACUITY (Distance)
UNCORRECTED
CORRECTED
HORIZONTAL FIELD OF VISION
Can applicant recognize and distinguish
Right Eye
20/______
20/______
Right Eye
degrees
among traffic control signals and devices
Left Eye
20/______
20/______
Left Eye
degrees
showing standard red, green and amber
colors?
Yes
No
Both Eyes
20/______
20/______
Applicant meets visual acuity requirement only when wearing:______ Corrective lenses
Monocular Vision?:
Yes
No
Complete next line only if vision testing is done by an ophthalmologist or optometrist:
Date of Exam
Printed Name of Ophthalmologist/Optometrist
Signature
Telephone Number
License No/State of Issue
4. HEARING: Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in
better ear < 40 dB.
Check if hearing aid used for tests.
Check if hearing aid required to meet standard
INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500 Hz, -10 dB for 1,000 Hz, -8.5 Db for 2,000 Hz. To
average, add the readings for 3 frequencies tested and divide by 3.
Numerical readings must be recorded.
A) Record distance from individual at which forced whispered voice can first be heard.
Right Ear _______ ft.
Left Ear _______ ft.
B) If audiometer is used, record hearing loss in decibels.
500 Hz
1000 Hz
2000 Hz
Average
(Acc. To ANSI Z24.5-1951)
Right Ear
______
______
______
______
Left Ear
______
______
______
______
5. BLOOD PRESSURE/PULSE RATE - Numerical readings must be recorded. Medical Examiner should take at least two readings to
confirm BP.
Blood
Systolic
Diastolic
Reading
Category
Expiration Date
Recertification
Pressure
140-159/90-99
Stage 1
1 year
1 year if <140/90.
Driver qualified if <140/90.
One-time certificate for 3
months if 141-159/91-99.
Pulse Rate:
Regular
Irregular
160-179/100-109
Stage 2
One-time certificate for 3 months.
1 year from date of exam if
< 140/90
>180/110
Stage 3
6 months from date of exam if <140/90
6 months if <140/90
Record Pulse Rate:
NOTE: Medical Examiner should take at least 2 readings to confirm blood pressure prior to posting reading on this form.
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