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Medical Examination Report For Commercial Driver Fitness Determination

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Medical Examination Report For Commercial Driver Fitness Determination
Medical Examination Report For Commercial Driver Fitness Determination
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
M
F
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
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
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
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.
Yes No
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" answer
s and potential hazards of
medications, including over-the-counter medications, while driving. This discussion must be documented below. )
Yes No
2.
HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver.
Medical Examination Report For Commercial Driver Fitness Determination
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