Medical Examination Report
DOT Physical Exam NON-DOT Physical Exam
1. APPLICANT'S INFORMATION Applicant completes this section.
Driver's Name
Applicant's (Last,
Name (Last,First,
First,Middle)
Middle) Social Security Number Birth Date Age Gender New certification Date of Exam
Recertification
Follow Up
Address City, State, Zip Code Driver License No. License Class State of Issue
Work Phone:
A C
B D
Home Phone:
Other
2. HEALTH HISTORY Applicant completes this section, but medical examiner is encouraged to discuss with applicant.
Yes No 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
Ear disorders, loss of hearing or balance medication:
Heart disease or heart attack; other cardiovascular condition Loss of, or altered consciousness
medication: Fainting, dizziness
Heart surgery (valve replacement/bypass, angioplasty, Sleep disorders, pauses in breathing while asleep, daytime
pacemaker) sleepiness, loud snoring
High blood pressure Stroke or paralysis
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.
Applicant's Name (Last, First, Middle): Page - 2
TESTING (Medical Examiner completes Section 3 through 7)
Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal
3. VISION
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.
Yes No
Applicant can recognize and distinguish among traffic
Acuity Acuity Horizontal
control /signals and devices showing standard red, green,
Uncorrected Corrected Field of Vision
and amber colors.
Right Eye 20/ 20/ degrees Applicant meets visual acuity requirement only when
Left Eye 20/ 20/ degrees wearing corrective lenses.
Both Eyes 20/ 20/ Applicant only has monocular vision.
Complete next line only if vision testing is done by an opthalmologist or optometrist.
Date of Examination Name of Ophthalmologist or Optometrist (print) Telephone License No./ Signature
Number State of Issue
Standard: a) Must first perceive forced whispered voice •--
>= 5 ft., with or without hearing aid, or b) average hearing loss in
4. HEARING
better ear <= 40 dB. Check if hearing aid used for tests. Check if hearing aid required to meet standard.
INSTRUCTIONS: 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 frequencies tested and divide by 3.
a) Record distance from individual Right Ear Left Ear b) If audiometer is used, Right Ear Left Ear
at which forced whispered voice record hearing loss in decibels. 500 1000 2000 500 1000 2000
can first be heard. feet feet (according to ANSI Z24.5-1951)
Average
BLOOD PRESSURE/
5. PULSE RATE
Standard: Applicant qualified if 140/90 or less. Medical Examiner should take at least two readings to confirm BP.
Blood Pressure Reading Category Expiration Date Recertification
Systolic Diastolic 1 year if 140/90 or less.
140-159/90-99 Stage 1 Certified for one year One-time certificate for 3 months
if 141-159/91-99.
1 year from date of exam if 140/90
160-179/100-109 Stage 2 One time certificate for three months
or less.
Pulse
Regular
Rate 180/110 or greater Stage 3 6 months from date of exam 6 months if 140/90 or less.
Irregular
if <140/90
LABORATORY AND Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule
6. OTHER TEST FINDINGS out any underlying medical problem.
Specific Gravity Protein Blood Sugar
Urinalysis
Other Testing (Describe and record)
7. VITALS Height: Weight: FSBS: BMI: ESS:
Applicant's Name (Last, First, Middle): Page - 3
PHYSICAL
8.7.
EXAMINATION
BODY SYSTEM CHECK FOR YES NO BODY SYSTEM CHECK FOR YES NO
Enlarged liver, enlarged spleen, masses, bruits,
General Marked overweight, tremor, signs of alcoholism, 7. Abdomen and
hernia, significant abdominal wall muscle
Appearance problem drinking, or drug abuse. Viscera
weakness.
Pupillary equality, reaction to light, Abnormal pulse and amplitude, carotid or arterial
accommodation, ocular motility, ocular muscle 8. Vascular system
bruits, varicose veins.
imbalance, extraocular movement, nystagmus,
2. Eyes 9. GU System Hernias.
exophthalmos. Ask about retinopathy, cataracts,
aphakia, glaucoma, macular degeneration and Impaired equilibrium, coordination or speech
refer to a specialist if appropriate. pattern; paresthesia, asymmetric deep tendon
12. Neurological
Scarring of tympanic membrane, occlusion of reflexes, sensory or positional abnormalities,
3. Ears abnormal patellar and Babinski's reflexes, ataxia.
external canal, perforated eardrums.
4. Mouth and Irremediable deformities likely to interfere with 11. Spine, other Previous surgery, deformities, limitation of motion,
Throat breathing or swallowing. musculoskeletal tenderness.
Murmurs, extra sounds, enlarged heart,
5. Heart pacemaker, implantable defibrillator. 10. Extremities – Loss or impairment of leg, foot, toe, arm, hand,
Limb impaired. finger. Perceptible limp, deformities, atrophy,
Abnormal chest wall expansion, abnormal Driver may be weakness, paralysis, clubbing, edema, hypotonia.
respiratory rate, abnormal breath sounds subject to SPE Insufficient grasp and prehension in upper limb to
6. Lungs and
including wheezes or alveolar rales, impaired certificate if maintain steering wheel grip. Insufficient mobility
chest, not
respiratory function, cyanosis. otherwise and strength in lower limb to operate pedals
including breast
Abnormal findings on physical exam may require qualified. properly.
examination
further testing such as pulmonary tests and/or
xray of chest.
Comments:
Medical Examiner Signature: Date:
NON DOT EXAM
Note certification status here. Wearing corrective lenses
See Instructions to the Medical Examiner for guidance. Wearing hearing aid
Accompanied by a waiver/exemption. Driver
Meets standards in 49 CFR 391.41; qualifies for 2 year certificate must present exemption at time of certification.
Does not meet standards Skill Performance Evaluation (SPE) Certificate
Temporarily disqualified due to (condition or medication) Driving within an exempt intracity zone (See 49 CFR 391.62)
Meets standards, but periodic evaluation required. Qualified by operation of 49 CFR 391.64
Due to applicant qualified only for:
MEDICAL CERTIFIER
3 months 6 months 1 year Other:
Signature:
Follow up
Name (print):
Address:
City, St, Zip:
Expiration date: Telephone:
If meets standards, complete a Medical Examiner's Certificate according to 49 CFR 391.43 (h).
(Driver must carry certificate when operating a commercial vehicle.)
NON DOT EXAM Non-DOT Medical Examination Results
General Physical Examination Conclusions: Satisfactory Pending Rejection Cause for Rejection
I certify that I have answered all of the above questions, that I have carefully
considered my answers, and that I have disclosed all of the information completely and
accurately as requested by the medical examiner for answers to the above questions. SIGNATURE OF APPLICANT:
The information I have provided regarding this physical examination is true and
complete. A complete examination form with any attachment embodies my findings
completely and correctly and is on file in my office
PLEASE PRINT NAME AND ADDRESS OF MEDICAL EXAMINER SIGNATURE OF EXAMINER:
