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Personal Information
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Last Name
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First Name
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Middle Initial
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Date of Birth
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Age
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Street Address
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City
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State
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Zip code
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Driver License Number
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Issuing State
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Phone Number
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Email
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New Short Text Field
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CLP/CDL Applicant/ Holder?
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Driver ID Verified By***?
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Has your USDOT/FMCSA ever been denied or issued for less than 2 years?
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Have you ever had surgery? If yes please explain below.
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Are you currently taking medications? (Perscription, over-the-counter, herbal remedies, diet supplements)
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Last Name
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First Name
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DOB
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Exam Date
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Do you have, or have you ever had?
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1. Head/Brain injuries or illness (I.e. concussion)
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16. Dizziness, headaches, numbness, tingling, or memory loss
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2. Seziures/ Epilepsy
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17. Unexplained weight loss
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3. Eye Problems (Except Glasses or contacts)
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18. Stroke, mini-stroke (TIA), paralysis, or weakness
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4. Ear and/or Hearing Problems
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19. Missing or limited use of arm, hand, finger, leg, foot, toe
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5. Heart disease, heart attack, bypass, or other heart problems?
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20. Neck or back problems
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6. Pacemaker, stents, implantable devices, or other heart procedures
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21. Bone, muscle, joint, or nerve problems
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7. High blood pressure
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22. Blood clots or bleeding problems
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8. High cholesterol
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23. Cancer
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9. Chronic (long-term) cough, shortness of breath, or other breathing problems
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24. Chronic (long-term) infection or other chronic diseases
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10. Lung disease (e.g., asthma)
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25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
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11. Kidney problems, kidney stones, or pain/problems with urination
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26. Have you ever had a sleep test (e.g., sleep apnea)?
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12. Stomach, liver, or digestive problems
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27. Have you ever spent a night in the hospital?
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13. Diabetes or blood sugar problems
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28. Have you ever had a broken bone?
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Insulin used
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29. Have you ever used or do you now use tobacco?
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14. Anxiety, depression, nervousness, other mental health problems
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30. Do you currently drink alcohol?
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15. Fainting or passing out
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31. Have you used an illegal substance within the past two years?
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32. Have you ever failed a drug test or been dependent on an illegal substance?
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Other health condition(s) not described above:
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Did you answer “yes” to any of questions 1-32? If so, please comment further on those health conditions below:
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CMV Driver's Signature
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Driver Signature
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Date
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SECTION 2. Examination Report (to be filled out by the medical examiner)
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DRIVER HEALTH HISTORY REVIEW
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Attach more sheets if nescessary
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Last Name
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First Name
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DOB
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Exam Date
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Testing
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Pulse Rate
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Pulse/ Rhythm regular?
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Height (ft/in)
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Weight (lbs)
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Blood Pressure (Sitting)
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Urinalysis
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Blood Pressure (Second Reading)
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Urinalysis
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Other testing if indicated
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Vision
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Hearing
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Aquity
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Check if hearing aid used for test
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Right Eye (Uncorrected)
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Whisper Test
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Left Eye (Uncorrected)
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New Fraction Field
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Both Eyes (Uncorrected)
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Right ear Audiometric Test Results
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Right Eye
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Average Right
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Left Eye
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Left ear Audiometric Test Results
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Both Eyes
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Average Left
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Right Eye Horizontal Field of Vision
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Left Eye Horizontal Field of Vision
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Physical Examination
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Body System
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1. General (Normal?)
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8. Abdomen (Normal?)
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2. Skin (Normal?)
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9. Genito-urinary system including hernias (Normal?)
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3. Eyes (Normal?)
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10. Back/spine (Normal?)
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4. Ears (Normal?)
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11. Extremities/joints (Normal?)
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5. Mouth/ Throat (Normal?)
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12. Neurological system including reflexes(Normal?)
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6. Cardiovascular (Normal?)
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13. Gait (Normal?)
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7. Lungs/ Chest (Normal?)
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14. Vascular system (Normal?)
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Discuss
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Last Name
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First Name
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DOB
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Exam Date
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MEDICAL EXAMINER DETERMINATION (Federal)
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Does not meet standards (specify reason):
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Meets standards in 49 CFR 391.41; qualifies for 2-year certificate
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Meets standards, but periodic monitoring required (specify reason):
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Driver Qualified for
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Qualified
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Determination pending (specify reason):
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Return to medical exam office for follow-up on (must be 45 days or less):
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Medical Examination Report amended (specify reason):
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(if amended) Medical Examiner’s Signature:
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Date
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Incomplete examination (specify reason):
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If the driver meets the standards outlined in 49 CFR 391.41, then complete a Medical Examiner’s Certificate as stated in 49 CFR
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Medical Examiner’s Signature:
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Medical Examiner’s Name (please print or type):
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Medical Examiner’s Address:
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City
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State
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Zip code
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Medical Examiner's Phone Number
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Date Certificate Signed
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Medical Examiner’s State License, Certificate, or Registration Number:
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Issueing State
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Provider Type
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National Registry Number
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Medical Examiner's Cert Experation Date
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