DOT Physical Exam Form

DOT Physical Form

Form MCSA-5875
PERSONAL INFORMATION
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Age*
Email
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State/Province*
Zip Code*
Driver's License Number*
Issuing State/Province*
Phone*
Exam Date

MonthDayYear
Date
Gender:*

MF
E-mail (optional)
example@example.com
CLP/CDL Applicant/Holder:*

YesNo
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?*

YesNoNot Sure
DRIVER HEALTH HISTORY
Have you ever had surgery? If "yes," please list and explain below.*

YesNoNot Sure
Explain
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If "yes," please describe below.*

YesNoNot Sure
If "yes," please describe below.
Include the medication name, dose, and the frequency you take the medication.

Do you or have you ever had:*

	Yes	No	Not Sure
1. Head/brain injuries or illnesses (e.g., concussion)
2. Seizures, epilepsy
3. Eye problems (except glasses or contacts)
4. Ear and/or hearing problems
5. Heart disease, heart attack, bypass, or other heart problems
6. Pacemaker, stents, implantable devices, or other heart procedures
7. High blood pressure
8. High cholesterol
9. Chronic (long-term) cough, shortness of breath, or other breathing problems
10. Lung disease (e.g., asthma)
11. Kidney problems, kidney stones, or pain/problems with urination
12. Stomach, liver, or digestive problems
13. Diabetes or blood sugar problems Insulin used
Insulin used
14. Anxiety, depression, nervousness, other mental health problems
15. Fainting or passing out
16. Dizziness, headaches, numbness, tingling, or memory loss
17. Unexplained weight loss
18. Stroke, mini-stroke (TIA), paralysis, or weakness
19. Missing or limited use of arm, hand, finger, leg, foot, toe
20. Neck or back problems
21. Bone, muscle, joint, or nerve problems
22. Blood clots or bleeding problems
23. Cancer
24. Chronic (long-term) infection or other chronic diseases
25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
26. Have you ever had a sleep test (e.g., sleep apnea)?
27. Have you ever spent a night in the hospital?
28. Have you ever had a broken bone?
29. Have you ever used or do you now use tobacco?
30. Do you currently drink alcohol?
31. Have you used an illegal substance within the past two years?
32. Have you ever failed a drug test or been dependent on an illegal substance?

Did you answer "yes" to any of questions 1-32?*

YesNoNo
If so, please comment further on those health conditions below:
Do you have any other health condition(s) not described above*

YesNoNot Sure
Please explain:
CMV DRIVER'S SIGNATURE
Driver's Signature*

Clear
Date Signed

MonthDayYear
File Upload

Please submit any documents that you need to here. Examples: CPAP compliance reports, A1C results, or medication lists.
Cancelof
Should be Empty:

DOT Physical Form

PERSONAL INFORMATION

DRIVER HEALTH HISTORY

CMV DRIVER'S SIGNATURE