Form 649-F - Medical Examination Report - Federal Motor Carrier Safety Administration Page 3
ADVERTISEMENT
1
2
3
4
5
6
7
8
9Height:
(in.) Weight:
(lbs.)
7
PHYSICAL EXAMINATION
Name:
Last,
First,
Middle,
7.
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 the condition, if neglected, could result in more serious illness that might affect driving.
Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's
ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for.
See Instructions to the Medical Examiner for guidance.
YES* NO
BODY SYSTEM
CHECK FOR:
BODY SYSTEM
CHECK FOR:
YES* NO
1. General Appearance
Marked overweight, tremor, signs of alcoholism, problem
drinking, or drug abuse.
7. Abdomen and Viscera
Enlarged liver, enlarged spleen, masses, bruits,
hernia, significant abdominal wall muscle
weakness.
2. Eyes
Pupillary equality, reaction to light, accommodation, ocular
motility, ocular muscle imbalance, extraocular movement,
8. Vascular System
Abnormal pulse and amplitude, cartoid or
nystagmus, exophthalmos. Ask about retinopathy, cataracts,
arterial bruits, varicose veins.
aphakia, glaucoma, macular degeneration and refer to a
specialist if appropriate.
9. Genito-urinary System
Hernias.
3. Ears
Scarring of tympanic membrane, occlusion of external canal,
Loss or impairment of leg, foot, toe, arm, hand,
10. Extremities- Limb
finger, Perceptible limp, deformities, atrophy,
perforated eardrums.
impaired. Driver may
weakness, paralysis, clubbing, edema,
4. Mouth and Throat
be subject to SPE
hypotonia. Insufficicent grasp and prehension
Irremediable deformities likely to interfere with breathing or
certificate if otherwise
in upper limb to maintain steering wheel grip.
swallowing.
qualified.
Insufficient mobility and strength in lower limb
to operate pedals properly.
5. Heart
Murmurs, extra sounds, enlarged heart, pacemaker,
implantable defibrillator.
11. Spine, other
Previous surgery, deformities, limitation of
musculoskeletal
motion, tenderness.
6. Lungs and chest,
Abnormal chest wall expansion, abnormal respiratory rate,
Impaired equilibrium, coordination or speech
not including breast
abnormal breath sounds including wheezes or alveolar rales,
12. Neurological
pattern; asymmetric deep tendon reflexes,
examination
impaired respiratory function, cyanosis. Abnormal findings on
sensory or positional abnormalities, abnormal
physical exam may require further testing such as pulmonary
patellar and Babinki's reflexes, ataxia.
tests and/ or xray of chest.
*COMMENTS:
Note certification status here. See Instructions to the Medical Examiner for guidance.
Wearing corrective lense
Wearing hearing aid
Meets standards in 49 CFR 391.41; qualifies for 2 year certificate
Accompanied by a
waiver/ exemption. Driver must present
Does not meet standards
exemption at time of certification.
Meets standards, but periodic monitoring required due to
.
Skill Performanc e Evaluation (SPE) Certificate
Driver qualified only for:
3 months
6 months
1 year
Other
Driving within an exempt intracity zone (See 49 CFR 391.62)
Qualified by operation of 49 CFR 391.64
Medical Examiner's signature
Temporarily disqualified due to (condition or medication):
Medical Examiner's name
Address
Return to medical examiner's office for follow up on
Telephone Number
If meets standards, complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h). (Driver must carry certificate when operating a commercial vehicle.)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal