Form Mcsa-5875 - Medical Examination Report Form Page 2
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3Form MCSA-5875 (Revised: 04/01/2013)
Last Name:
First Name:
Middle Initial:
Date:
Page 2
DRIVER LIFESTYLE QUESTIONS
Yes No
Yes No
35. Have you ever used or do you now use tobacco?
37. Have you used an illegal substance within the past 2 years?
36. Do you currently drink alcohol?
38. Have you ever failed a drug test or been dependent on an
illegal substance?
DRIVER SIGNATURE
A driver is expected to provide the medical examiner with an accurate and complete medical history, as indicated in this Form that is part of
49 CFR
391.43. A driver who provides fraudulent or intentionally false information is in violation of
49 CFR
390.35, and would be subject to the penalties under
49 CFR
390.37.
Driver's Signature:
Date:
SECTION 2. Examination Report (to be filled out by the medical examiner)
Review and discuss pertinent driver answers and any available medical records
Comment on the driver's responses to the "health history" questions that may affect the driver's safe operation of a commercial motor vehicle (CMV).
(Attach additional sheets if necessary)
TESTING
Last Name:
First Name:
Middle Initial:
Height:
feet
inches Weight:
pounds
Neck circumference (optional)*:
inches BMI (optional)*:
Pulse rate:
Pulse rhythm regular:
Yes
No
*(Please note that a neck circumference greater than 17" for men/16" for women OR a body mass index greater than 33 are both risk factors for sleep apnea.)
Blood Pressure
Systolic
Diastolic
Urinalysis
Sp. Gr.
Protein
Blood
Sugar
Sitting
Urinalysis is required.
Numerical readings
Second reading
must be recorded.
(optional)
Protein, blood, or sugar in the urine may be an indication for further testing to
rule out any underlying medical problem.
Other testing if indicated (e.g., A1C, EKG; see FMCSA guidance)
Vision
Hearing
Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. At
Standard: Must first perceive whispered voice at greater than 5 feet (with or without
least 70° field of vision in horizontal meridian measured in each eye. The use of cor-
hearing aid OR average hearing loss in better ear at less than 40 dB.
rective lenses should be noted on the Medical Examiner's Certificate.
Check if hearing aid used for test:
Right Ear
Left Ear
Neither
Acuity
Uncorrected
Corrected
Horizontal Field of Vision
Whisper Test Results
Right Ear Left Ear
Record distance (in feet) from driver at which a forced
Right Eye:
20/
20/
Right Eye:
degrees
whispered voice can first be heard
Left Eye:
20/
20/
Left Eye:
degrees
OR
Audiometric Test Results
Both Eyes:
20/
20/
Yes No
Right Ear
Left Ear
Applicant can recognize and distinguish among traffic control
signals and devices showing red, green, and amber colors
500 Hz
1000 Hz
2000 Hz
500 Hz
1000 Hz
2000 Hz
Monocular vision
Referred to ophthalmologist or optometrist?
Average (right):
Average (left):
Received documentation from ophthalmologist or optometrist?
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