Medical Examination Report
FOR COMMERCIAL DRIVER FITNESS DETERMINATION
649-F (6045)
1. DRIVER'S INFORMATION Driver completes this section
Driver's Name (Last, First, Middle)
Social Security No.
Birthdate (M / D / Y)

Age
Sex
New Certification
Recertification
Follow-up
Date of Exam
Address
City, State, Zip Code
Work Tel:
Home Tel:
Driver License No.
License Class
A B C D
Other
State of Issue
2. HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver.
Yes No  
Any illness or injury in the last 5 years?
Head/Brain injuries, disorders or illnesses
Seizures, epilepsy
medication
Eye disorders or impaired vision (except corrective lenses)
Ear disorders, loss of hearing or balance
Heart disease or heart attack; other cardiovascular condition
medication
Heart surgery (valve replacement/bypass, angioplasty,pacemaker)
High blood pressure
medication
Muscular disease
Shortness of breath
Yes No  
Lung disease, emphysema, asthma, chronic bronchitis
Kidney disease, dialysis
Liver disease
Digestive problems
Diabetes or elevated blood sugar controlled by:
diet
pills
insulin
Nervous or psychiatric disorders, e.g., severe depression
medication
Loss of, or altered consciousness
Yes No  
Fainting, dizziness
Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
Stroke or paralysis
Missing or impaired hand, arm, foot, leg, finger, toe
Spinal injury or disease
Chronic low back pain
Regular, frequent alcohol use
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.
Driver's Signature
Date

Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of medications, including over-the-counter medications, while driving. This discussion must be documented below. )
TESTING (Medical Examiner completes Section 3 through 7) Name: Last, First, Middle,

3. VISION Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal 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.

Numerical readings must be provided.
ACUITY UNCORRECTED CORRECTED HORIZONTAL FIELD OF VISION
Right Eye
20/
20/
Right Eye
 degrees
Left Eye
20/
20/
Left Eye
 degrees
Both Eyes
20/
20/
 

Applicant can recognize and distinguish among traffic control signals and devices showing standard red, green, and amber colors? Yes No
Applicant meets visual acuity requirement only when wearing:
Corrective Lenses
Monocular Vision: Yes No

Complete next line only if vision testing is done by an opthalmologist or optometrist
Date of Examination Name of Ophthalmologist or Optometrist (print) Tel. No. License No./ State of Issue Signature

4. HEARING Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in 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.

Numerical readings must be recorded.

a) Record distance from individual at which forced whispered voice can first be heard.
Right ear
\ Feet
Left ear
\ Feet
b) If audiometer is used, record hearing loss in decibels. (acc. to ANSI Z24.5-1951)
Right Ear
500 Hz
1000 Hz
2000 Hz
Average:
Left Ear
500 Hz
1000 Hz
2000 Hz
Average:

5. BLOOD PRESSURE / PULSE RATE Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.

Blood Pressure
Systolic
Diastolic
Driver qualified if <140/90.
Pulse Rate: Regular Irregular
Record Pulse Rate:
Reading Category Expiration Date Recertification
140-159/90-99 Stage 1 1 year 1 year if <140/90.  One-time certificate for 3 months if 141-159/91-99.
160-179/100-109 Stage 2 One-time certificate for 3 months. 1 year from date of exam if <140/90
>180/110 Stage 3 6 months from date of exam if <140/90 6 months if < 140/90

6. LABORATORY AND OTHER TEST FINDINGS Numerical readings must be recorded.
URINE SPECIMEN
SP. GR.
PROTEIN
BLOOD
SUGAR
Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problem.
Other Testing (Describe and record)
7. PHYSICAL EXAMINATION
Height: (in.)
Weight: (lbs.)
Name: Last, First, Middle,
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.
BODY SYSTEM CHECK FOR: YES* NO
1. General Appearance Marked overweight, tremor, signs of alcoholism, problem
drinking, or drug abuse.
2. Eyes Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extraocular movement, nystagmus, exophthalmos. Ask about retinopathy, cataracts, aphakia, glaucoma, macular degeneration and refer to a specialist if appropriate.
3. Ears Scarring of tympanic membrane, occlusion of external canal, perforated eardrums.
4. Mouth and Throat Irremediable deformities likely to interfere with breathing or swallowing.
5. Heart Murmurs, extra sounds, enlarged heart, pacemaker, to operate pedals properly.
6. Lungs and chest, not including breast examination Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales, impaired respiratory function, cyanosis. Abnormal findings on physical exam may require further testing such as pulmonary tests and/ or xray of chest.
BODY SYSTEM CHECK FOR: YES* NO
7. Abdomen and Viscera Enlarged liver, enlarged spleen, masses, bruits,
hernia, significant abdominal wall muscle weakness.
8. Vascular System Abnormal pulse and amplitude, cartoid or arterial bruits, varicose veins.
9. Genito-urinary System Hernias.
10. Extremities- Limb impaired. Driver may be subject to SPE certificate if otherwise qualified. Loss or impairment of leg, foot, toe, arm, hand, finger, Perceptible limp, deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia. Insufficicent grasp and prehension in upper limb to maintain steering wheel grip.  Insufficient mobility and strength in lower limb to operate pedals properly.
11. Spine, other musculoskeletal Previous surgery, deformities, limitation of motion, tenderness.
12. Neurological Impaired equilibrium, coordination or speech pattern; asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar and Babinki's reflexes, ataxia.

*COMMENTS:


Note certification status here. See Instructions to the Medical Examiner for guidance.

Meets standards in 49 CFR 391.41; qualifies for 2 year certificate
Does not meet standards

Meets standards, but periodic monitoring required due to

Driver qualified only for: 3 months 6 months 1 year Other

Wearing corrective lense
Wearing hearing aid
Accompanied by a waiver/ exemption. Driver must present exemption at time of certification.
Skill Performanc e Evaluation (SPE) Certificate
Driving within an exempt intracity zone (See 49 CFR 391.62)
Qualified by operation of 49 CFR 391.64


Temporarily disqualified due to (condition or medication):

Return to medical examiner's office for follow up on
Medical Examiner's signature
Medical Examiner's name
Address
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.)

Press the "Save As PDF" button below to save the form as a PDF. You can then email the PDF document to Dr. Hayden.

If you prefer a printed version, press the "Save As PDF" button below, then click on "Open". From within Adobe you can then select "Print".