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Medical Examination Report

DOT Physical Exam

NON-DOT Physical Exam

APPLICANT'S INFORMATION

Applicant completes this section.

Driver's Name (Last, First, Middle)

Social Security Number

Birth Date

Age

Gender

Date of Exam

Applicant's Name (Last, First, Middle)

New certification

Recertification

Follow Up

Address

City, State, Zip Code

Driver License No.

License Class

State of Issue

Work Phone:

Home Phone:

Other

HEALTH HISTORY

Applicant completes this section, but medical examiner is encouraged to discuss with applicant.

Yes No

Any illness or injury in last 5 years?

Liver disease

Head/Brain injuries, disorders or illnesses

Digestive problems

Seizures, epilepsy

Diabetes or elevated blood sugar controlled by:

medication:

diet

pills

insulin

Eye disorders or impaired vision (except corrective lenses)

Nervous or psychiatric disorders, e.g., severe depression

medication:

Ear disorders, loss of hearing or balance

Loss of, or altered consciousness

Heart disease or heart attack; other cardiovascular condition

medication:

Fainting, dizziness

Heart surgery (valve replacement/bypass, angioplasty,

Sleep disorders, pauses in breathing while asleep, daytime

pacemaker)

sleepiness, loud snoring

Stroke or paralysis

High blood pressure

medication:

Missing or impaired hand, arm, foot, leg, finger, toe

Muscular disease

Spinal injury or disease

Shortness of breath

Chronic low back pain

Lung disease, emphysema, asthma, chronic bronchitis

Regular, frequent alcohol use

Kidney disease, dialysis

Narcotic or habit forming drug use

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.

_____________________________________________________

______________

Applicant's Signature

Date

Medical Examiners Comments on Health History

(The medical examiner must review and discuss with the applicant any "yes" answers and potential hazards of medications, including

over-the-counter medications, while driving.)

INSTRUCTIONS: The presence of a certain condition may not necessarily disqualify an applicant, 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 an applicant, the medical examiner may consider deferring the

applicant 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, and indicate whether it would affect the applicant'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.