Physical Examination Form - Washington Department Of Transportation

ADVERTISEMENT

Physical Examination
(VALID FOR NOT MORE THAN TWO YEARS FROM DATE OF EXAM)
After August 1, 2012, new examinations must provide a US Department of Transportation Medical Examiner's Certificate, completed
within the past 90 days by an examiner meeting the US Department of Transportation standards under 49 CFR 391.41 - 391.49.
PLEASE PRINT
DRIVER’S NAME
Last
First
Middle
(AREA CODE) TELEPHONE NUMBER
STREET ADDRESS
CITY
STATE
ZIP
DATE OF BIRTH
TO BE COMPLETED BY MEDICAL EXAMINER (
Please Print)
Answer each question yes or no where appropriate. The medical examiner should be aware of the rigorous physical demands and mental and emotional
responsibilities placed on the driver of a limousine vehicle. In the interest of public safety the medical examiner is required to certify that the driver does not have
any physical, mental, or organic defect of such a nature as to affect the driver’s ability to operate a limousine vehicle.
Health History:
Height: ______ft._____in.
Weight: __________lbs.
Yes
No
Yes
No
Yes
No
Diabetes
Muscular disease
Nervous stomach
Psychiatric disorder
Rheumatic fever
Syphilis
Cardiovascular disease
Asthma
Gonorrhea
Head or spinal injuries
Kidney disease
Extensive confinement by illness or injury
Seizures, fits, convulsions, or fainting
Tuberculosis
Suffering from any other disease
Any other nervous disorder
Gastrointestinal ulcer
Permanent defect from illness, disease or injury
If the answer to any of the above is yes, explain in General Comments section below.
General appearance and development:
Good _____________________ Fair __________________________ Poor _________________________
Vision:
For distance:
Right 20/ ________
Left 20/ _________
Without corrective lenses
With corrective lenses, if worn
Horizontal field of vision:
Right ______________________
Left _______________________
Evidence of disease or injury:
Right ___________________
Left _______________________
Color test ______________________________________________________________________________________________________
Hearing:
Right ear ___________________________________ Left ear _____________________________________________________________
Disease or injury _________________________________________________________________________________________________
Audiometric test: (If audiometer is used to test hearing)
Decibel loss at 500 Hz ________
at 1,000 Hz ___________
at 2,000 Hz ____________
Throat:
______________________________________________________________________________________________________________
Thorax:
Heart __________________________________________________________________________________________________________
If organic disease is present, is it fully compensated? ____________________________________________________________________
Blood pressure:
Systolic ____________________________________
Diastolic _________________________________________
Pulse:
Before exercise______________________________
Immediately after exercise ___________________________
Lungs: _________________________________________________________________________________________________________
Abdomen:
Scars __________________________
Abnormal masses _______________________
Tenderness _________________________
Hernia:
Yes
No
If so, where? ________________________________
Is truss worn? _____________________________
Gastrointestinal:
Ulceration or other disease ______________________________________________________________________________________
Genito-Urinary:
Scars _______________________________________________________________________________________________________
Reflexes:
Romberg _______________________________________________________________________________________________________
Pupillary _______________________________________ Light
Right ____________________
Left ______________________
Accommodation:
Right ___________________________________________
Left _____________________________________
Knee Jerks:
Right:
Normal _________________
Increased _____________________
Absent __________________
Left:
Normal _________________
Increased _____________________
Absent __________________
Extremities:
Upper _____________________________
Lower ________________________________
Spine ___________________________
Laboratory
Urine:
Spec. Gr. _______________________
Alb. _____________________________
Sugar __________________________
and other
Other laboratory data (Serology, etc.) ______________________________________________________________________________
special findings:
Radiological data ________________________________________
Electrocardiograph ____________________________________
General Comments: ___________________________________________________________________________________
Check here if
___________________________________________________________________________________________________
NOT qualified
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Medical Examiner _______________________________________________
License/Cert. No. & State _______________________________________
PRINT NAME & TITLE
Address _____________________________________________________________________________________________________________________
X
Medical Examiner _______________________________________________
Date of Examination ___________________________________________
SIGNATURE MUST APPEAR HERE
For assistance or to request this document in an alternate format, visit or call 1-800-451-7985. Teletype (TTY) users may call 360-705-6718.
BLS-700-340 (01/13/12)

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go