"Medical Examination Report Template"

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Medical Examination Report
DOT Physical Exam
NON-DOT Physical Exam
1.
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:
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
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.
Medical Examination Report
DOT Physical Exam
NON-DOT Physical Exam
1.
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:
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
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.
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
wearing corrective lenses.
Left Eye
20/
20/
degrees
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.
Right Ear Left Ear
Right Ear
Left Ear
a) Record distance from individual
b) If audiometer is used,
at which forced whispered voice
record hearing loss in decibels.
500
1000
2000
500
1000
2000
feet
feet
can first be heard.
(according to ANSI Z24.5-1951)
Average
BLOOD PRESSURE/
5.
Standard: Applicant qualified if 140/90 or less. Medical Examiner should take at least two readings to confirm BP.
PULSE RATE
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
One time certificate for three months
160-179/100-109
Stage 2
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:
7. Abdomen and
2. Eyes
8. Vascular system
9. GU System
3. Ears
4. Mouth and
Throat
10. Extremities –
11. Spine, other
5. Heart
12. Neurological
6. Lungs and
N ON
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,
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
bruits, varicose veins.
imbalance, extraocular movement, nystagmus,
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
reflexes, sensory or positional abnormalities,
Scarring of tympanic membrane, occlusion of
abnormal patellar and Babinski's reflexes, ataxia.
external canal, perforated eardrums.
Irremediable deformities likely to interfere with
Previous surgery, deformities, limitation of motion,
breathing or swallowing.
musculoskeletal
tenderness.
Murmurs, extra sounds, enlarged heart,
Loss or impairment of leg, foot, toe, arm, hand,
pacemaker , implantable defibrillator.
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
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:
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.
Skill Performance Evaluation (SPE) Certificate
Does not meet standards
Driving within an exempt intracity zone (See 49 CFR 391.62)
Temporarily disqualified due to (condition or medication)
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:
Telephone:
Expiration date:
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
SIGNATURE OF EXAMINER:
PLEASE PRINT NAME AN
D ADDRESS OF MEDICAL EXAMINER
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