Cdl Physical Examination Form (Page 3 of 8) in pdf

NAME: ___________________________________________________

6. LABORATORY AND OTHER TEST FINDINGS

Numerical readings must be recorded.

Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problems.

Sp. Gr.

Protein

Blood

Sugar

URINE SPECIMEN:

_______________

Other Tests (Describe and record) ______________________________________________________________________________________

7. PHYSICAL EXAMINATION

Height: ____________ (inches)

Weight: ____________(lbs)

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

to worsen or is readily amendable 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

the condition, if neglected, could result in more serious illness that might affect driving.

Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below and

indicate whether it would affect the driver’s ability to operate a commercial motor vehicle safely. Enter applicable item number before each

comment. If organic disease is present, note that it has been compensated for. See Instructions to the Medical Examiner for guidance.

BODY SYSTEM

CHECK FOR:

YES*

1. General appearance

Marked overweight, tremor, signs of alcoholism, problem drinking,

or drug abuse.

2. Eyes

Pupillary equality, reaction to light, accommodation, ocular motility,

ocular muscle imbalance, extraocular movement, nystagmus,

exophthalmos, strabismus uncorrected by corrective lenses, retinopathy,

cataracts, aphakia, glaucoma, macular degeneration. Refer to a

specialist if appropriate.

3. Ears

Scarring of the tympanic membrane, occlusion of external canal,

perforated eardrums.

4. Mouth and Throat

Irremediable deformities likely to interfere with breathing or swallowing.

5. Heart

Murmurs, extra sounds, enlarged heart, pacemaker, implantable

defibrillator.

6. Lungs and chest,

Abnormal chest wall expansion, abnormal respiratory rate, abnormal

not including breast

breath sounds including wheezes or alveolar rates, impaired respiratory

examination

function, cyanosis. Abnormal findings on physical exam may require

further testing such as pulmonary tests and/or x-ray of chest.

7. Abdomen and Viscera

Enlarged liver, enlarged spleen, masses, bruits, hernia, significant

abdominal wall muscle weakness.

8. Vascular system

Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins.

9. Genito-urinary systems

Hernias.

10. Extremities - Limbs

Loss or impairment of leg, foot, toe, arm, hand, finger. Perceptible limp,

impaired. Driver may

deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia.

be subject to SPE

Insufficient mobility and strength in lower limb to operate pedals properly.

certificate if otherwise

Insufficient grasp and prehension in upper limb to maintain steering

qualified.

wheel grip.

11. Spine, other

Previous surgery, deformities, limitation of motion, tenderness

musculoskeletal

12. Neurological

Impaired equilibrium, coordination or speech pattern; paresthesia,

asymmetric deep tendon reflexes, sensory or positional abnormalities,

abnormal patellar and Babinski’s reflexes, ataxia.

*Comments

Cdl Physical Examination Form Page 3

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