Form Mcsa-5875 - Medical Examination Report Form Page 3
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3Form MCSA-5875 (Revised: 04/01/2013)
Last Name:
First Name:
Middle Initial:
Date:
Page 3
PHYSICAL EXAMINATION
The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or
is readily amenable 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 neglecting the condition could
result in a more serious illness that might affect driving.
Check if the body system is normal, or if there are any abnormalities. Discuss any abnormal answers in detail in the space below and indicate whether it
would affect the driver's ability to operate a CMV. Enter applicable item number before each comment. If organic disease is present, note if it has been
compensated for.
Body System
Normal Abnormal
Body System
Normal Abnormal
1. General
8. Abdomen
2. Skin
9. Inguinal hernia (male only)
3. Eyes
10. Back
4. Ears
11. Extremities/joints
5. Mouth/throat
12. Spine
6. Heart
13. Neuro/reflexes
7. Lungs/chest
14. Gait
Impressions:
(Attach additional sheets if necessary)
MEDICAL EXAMINER DETERMINATION
Meets standards in 49 CFR 391.41; qualifies for 2-year certificate
Does not meet standards (explain why):
Meets standards, but periodic monitoring required (due to):
Driver qualified for:
3 months
6 months
1 year
other:
Wearing corrective lenses
Wearing hearing aid
Accompanied by a
waiver/exemption (Driver must present exemption certificate at time of certification)
Accompanied by a Skill Performance Evaluation (SPE) certificate
Driving within an exempt intracity zone (see 49 CFR 391.62)
Qualified by operation of 49 CFR 391.64
If the driver meets the standards outlined in
49 CFR
391.41, then complete a Medical Examiner's Certificate as stated in
49 CFR
391.43(h), as appropriate.
I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation,
and attest that to the best of my knowledge, I believe it to be true and correct.
Joel Grant, MD
Medical Examiner Signature:
Medical Examiner Name:
Date:
160 Warrior Drive
Stephens City
VA
22655-4044
(540) 868-4100
Address:
City:
State:
Zip Code:
Phone:
0101233394
Medical Examiner's License or Certificate Number:
MD
DO
Physician Assistant
Chiropractor
Advanced Practice Nurse
Other Practitioner
State issuing License or Certificate:
Virginia
2,417,451,507
National Registry Number:
Medical Certificate Expiration Date:
Determination pending (specify reason):
Return to medical exam office for follow-up on (must be 45 days or less):
Comment on reasons for amendment:
(if amended) Medical Examiner Signature:
Date:
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