Dot Physical Examination Medical Form (Page 2 of 2) in pdf

yr O1.%~UPt I A

LION

M~l1I

‘CQ~T*ETURN1Q ATA

Certilicatiort ~

Date of Examination

N e w

___________

Recertrtica~ion

Pfnt):

Filled In ~y Medical Examiner (Please

Chec~cHere ii Not Qualified

Drrver~sName

ACdress

_________________________________________________________

___________________

Soc.

Sec. No.

________________________________ Date of Birth

Age_~

______________________

_________

l4eslth His1ory~

Ye.

YeS

Yes No

P4eci~ousstomach

or Spinal inuriva

Asthma

pLead

Rheuinatc fever

l~1dney

Seizures, Its,

CoflVUl~i~na o r fainting

~IInQ~ or injury

Exfon$vO confinement by

?uberculouis

Mus~ulor disease

disorder

Paytha~

other r~rvous

Syphilis

Any

order

Oonorthea

frtsm ai~y

Catdiovascular disease

Su$eting

other ~saas~

ln~ury

disaasa or

Oiabin~c

faath~J ulcor

?~rrnsn~eIt ~l~t

from ~ess.

ff~1Swefba~ycIrrc 5 ~~~eq*il

___________

ddevdoprnent:

G~eesl a ppearance .

Good

Fair

Poor

_____________________

____________________

_________________

~0/~cth

i~cu~ c~rreclwa

With

l~nsas, it worn

For

~s~:

Rig~

lenses .1

~orrectJve

Vision:

20i_~__L~ft

Right

of disease

~~It~Y

Leh __________________________________

Evidence

•....

color Test

konz~’ital k id of vision:

Right

Loft

_____________________

—

______________

oar __________________________________ Left e

Hearing:

- ____________________

Disease

viji~ry

. .—

—

(if

000

2.000 ko

6.003

Audlomauje

suifiometeris e’secl ic teor h.arzn

) Dec~oet l oss at 500 Hz

4.000 l~tz

tut:

—

-—

—

Thrcat

Thorax:

—__________

disease is

seia,

hilly compsatad~

oginic

___________________________

- ________________________

y5~ti~

8I~d

presst~re:

____________________

____________

__________________

~zarcse

Pulse:

~eIcreexorcise

alt~n

lmrrtedwtely

_________________

Lungs

________

Abdomen:

Scars_____________________ Abnormal

Tenderness

m~ses

_______

Yas

~uss

Nemi~:

so. where?

worn?

________

________________________________

_______________

Ulceration ~r other diseasas: Ye6

~astroltnesdnal

____________

GsnftoUrln,ry:

Sczr~

Urethral

discharge

Rh~nber~

. -______

___________

Pupillery

Ligiw R

______________

________________

Left

Accom,~stion.

.. — _________

________________

Normal

Right:

Knee je&s:

_____________.

—

_________________

left

Normal

lncreaso~

Abseni

_________________

______________

______

Remarks:

______________________________________________________________

_______________________

. -

Lo~ner

~Ii.evitits:

-Upoer

______

_____________________

Sçec,

Su;ar

Laboratory and

Urine:

At~,

_________________

—

Othor 5psclsl

om~ U~oratcry ~?a~ l ~eroiogy,

S IC)

——.

,..~.

—

Findings:

Radiological Data

~EleCUCo~5pP1

Conitollod

Substances Teeting

Controlled sub~tancwc

a~nor~anoe

0 ~

Hat

OOCO~dOflCC with Subpart H

ti~ibpart

t wer ~

•

ConIroIle~substances

test NOT performEd

General CommunLs:

_________________

Medical

P4eme of

Examiner (Print)

Si~riature

Address

of M.dicag Examiner

MEDICAL EXAMINER’S

ONLY

DRIVER IS POUND QUALI~ED

CERTIFICATE TO BE COMPLETED

MEDICAL

CE*TIFICA’TE

ELUdIP4~RS

roamin~d

I ortly that I have

only when lh~

The followin

vnwel teat i~ Con~LCtOd

wig

completed

Eye

lic~nmnedcphthetmclcgrsl Or

Op1O?n~tTinL

~iaoor~sncr a iththe gedar~l

Re IaCa4’r$(49

I~t~r Carmle~ Saey

CFROPa

.41

iteoiiledge o hister~ne, I 0n~ tnlrns~irden

ofcaitificeS.

*ss regulanons. £zpiraflon ~t.

__________

wn.r~

wewin~.0 Coe’,cnv. liivie*

Ci Hum; so

Oumtir*4 oniy

Meacaily ueicu&l~r..a~

~C~”95ZllS’5 ~y.

_V.’~’~’S

WS’~’fl!

~dn

zone

U Med~fly ungs~sliteC itllees tdwng

mn~ny

&i uzamp:

A compleie~ examniriatcn form for 511$ por~mnison file in myOft~.

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fAreCoes?none ~°.i

ç..scarsecv~a. ‘ ~J

t5mae~

‘—se—,’,.

5e~nw.c

t’ent ~je,e ed Th~li

iSç.swu~

—

IAOer*n,

INSTRUCTIONS ON REVERSE SLOE

ni O’via’l

Dot Physical Examination Medical Form Page 2

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