DOT Physical Form
A DOT physical form, also known as a Department of Transportation physical form, is a standardized document used to assess the physical fitness of commercial motor vehicle drivers to ensure they meet the health and safety requirements necessary for operating commercial vehicles on public roads. This form is typically completed by a certified medical examiner and includes details about the driver's health, medical history, and physical examination results.
Public Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of
the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection
of information is estimated to be approximately 25 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All
responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to:
Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
U.S. Department of Transportation
Federal Motor Carrier
Safety Administration
Medical Examination Report Form
(for Commercial Driver Medical Certification)
SECTION 1. Driver Information (to be filled out by the driver)
PERSONAL INFORMATION
*CLP/CDL Applicant/Holder: See instructions for definitions
**Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver’s license, passport
DRIVER HEALTH HISTORY
If “yes,” please list and explain below
If “yes,” please describe below.
**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this
information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when
no longer required to be maintained by regulatory requirements.**
DRIVER HEALTH HISTORY (continued)
Do you have or have you ever had: |
Yes |
No |
Not Sure |
1. Head/brain injuries or illnesses (e.g., concussion) |
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2. Seizures/epilepsy |
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3. Eye problems (except glasses or contacts) |
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4. Ear and/or hearing problems |
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5. Heart disease, heart attack, bypass, or other heart problems |
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6. Pacemaker, stents, implantable devices, or other heart procedures |
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7. High blood pressure |
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8. High cholesterol |
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9. Chronic (long-term) cough, shortness of breath, or other breathing problems |
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10. Lung disease (e.g., asthma) |
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11. Kidney problems, kidney stones, or pain/problems with urination |
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12. Stomach, liver, or digestive problems |
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13. Diabetes or blood sugar problems Insulin used |
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14. Diabetes or blood sugar problems Insulin used |
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15. Fainting or passing out |
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16. Anxiety, depression, nervousness, other mental health problems |
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Yes |
No |
Not Sure |
17. Unexplained weight loss |
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18. Stroke, mini-stroke (TIA), paralysis, or weakness |
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19. Missing or limited use of arm, hand, finger, leg, foot, toe |
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20. Neck or back problems |
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21. Bone, muscle, joint, or nerve problems |
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22. Blood clots or bleeding problems |
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23. Cancer |
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24. Chronic (long-term) infection or other chronic diseases |
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25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring |
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26. Have you ever had a sleep test (e.g., sleep apnea)? |
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27. Have you ever spent a night in the hospital? |
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28. Have you ever had a broken bone? |
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29. Have you ever used or do you now use tobacco? |
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30. Do you currently drink alcohol? |
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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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If so, please comment further on those health conditions below:
