Form 649-F - Medical Examination Report For Commercial Driver Fitness Determination

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Medical Examination Report
FOR COMMERCIAL DRIVER FITNESS DETERMINATION
649-F (6045)
DRIVER'S INFORMATION
1.
Driver completes this section
Driver's Name (Last, First, Middle)
Social Security No.
Birthdate
Age
Sex
New Certification
Date of Exam
M
Recertification
M / D / Y
F
Follow-up
Address
City, State, Zip Code
Work Tel: ( )
Driver License No.
License Class
State of Issue
A
C
B
D
Home Tel: ( )
Other
HEALTH HISTORY
Driver completes this section, but medical examiner is encouraged to discuss with driver.
2.
Yes No
Yes No
Yes No
Lung disease, emphysema, asthma, chronic bronchitis
Fainting, dizziness
Any illness or injury in the last 5 years?
Kidney disease, dialysis
Sleep disorders, pauses in breathing
Head/Brain injuries, disorders or illnesses
Liver disease
while asleep, daytime sleepiness, loud
Seizures, epilepsy
snoring
Digestive problems
medication_______________________________
Diabetes or elevated blood sugar controlled by:
Stroke or paralysis
diet
Eye disorders or impaired vision (except corrective lenses)
Missing or impaired hand, arm, foot, leg,
pills
Ear disorders, loss of hearing or balance
finger, toe
insulin
Heart disease or heart attack; other cardiovascular condition
Spinal injury or disease
medication_______________________________
Nervous or psychiatric disorders, e.g., severe depression
medication____________________
Chronic low back pain
Heart surgery (valve replacement/bypass, angioplasty,
pacemaker)
Regular, frequent alcohol use
Loss of, or altered consciousness
High blood pressure
medication___________________
Narcotic or habit forming drug use
Muscular disease
Shortness of breath
For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including
over-the-counter medications) used regularly or recently.
I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my
Medical Examiner's Certificate.
Driver's Signature
Date
Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of
medications, including over-the-counter medications, while driving. This discussion must be documented below. )

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