Form 649-F - Medical Examination Report - Federal Motor Carrier Safety Administration Page 2

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TESTING (Medical Examiner completes Section 3 through 7)
Name: Last,
First,
Middle,
3.
VISION
Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian
measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.
INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a
ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver
habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.
Applicant can recognize and distinguish among traffic control
Numerical readings must be provided.
Yes
?
sign als and devices showing standard red, green, and amber colors
No
A A CUITY
CUITY
UNCORRECTED
UNCORRECTED
CORRECTED
CORRECTED
HORIZONTAL FIELD OF VISION
Applicant meets visual acuity requirement only when wearing:
Right Eye
Right Eye
20/
20/
20/
20/
Right Eye
Right Eye
Corrective Lenses
Left Eye
Left Eye
20/
20/
20/
20/
Left Eye
Left Eye
Monocular Vision:
Yes
No
Both Eyes
Both Eyes
20/
20/
20/
20/
Complete next line only if vision testing is done by an opthalmologist or optometrist
Date of Examination
Name of Ophthalmologist or Optometrist (print)
Tel. No.
License No./ State of Issue
Signature
4.
HEARING
Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB
Check if hearing aid used for tests.
Check if hearing aid required to meet standard.
To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3
INSTRUCTIONS:
frequencies tested and divide by 3
.
Numerical readings must be recorded.
Right Ear
Left Ear
a) Record distance from individual at which
Right ear
Left Ear
500 Hz
1000 Hz
2000 Hz 500 Hz
1000 Hz 2000 Hz
b) If audiometer is used, record hearing loss in
forced whispered voice can first be heard.
\
\ Feet
Feet
decibels. (acc. to ANSI Z24.5-1951)
Average:
Average:
5.
BLOOD PRESSURE/ PULSE RATE
Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.
Blood
Systolic
Diastolic
Reading
Category
Expiration Date
Recertification
Pressure
140-159/90-99
Stage 1
1 year
1 year if <140/90.
One-time certificate for 3 months if
Driver qualified if <140/90.
141-159/91-99.
Pulse Rate:
Regular
Irregular
160-179/100-109
Stage 2
One-time certificate for 3 months.
1 year from date of exam if <140/90
>180/110
Stage 3
6 months from date of exam if <140/90
6 months if < 140/90
Record Pulse Rate: __________
SP. GR.
PROTEIN
BLOOD SUGAR
6.
LABORATORY AND OTHER TEST FINDINGS
Numerical readings must be recorded.
URINE SPECIMEN
Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to
rule out any underlying medical problem.
Other Testing (Describe and record)

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