DOT/CDL Medical Exam Note (FMCSA)

Exam Date/Time: [Date and time]

Exam Type: [Initial / Recertification / Return-to-duty / Other (specify)]

Certification Basis: [Federal (interstate) / State (intrastate)]

Driver Category (CLP/CDL applicant or holder): [Yes / No]

Driver ID Verified: [Photo ID type used]

Driver Name: [Full name]

DOB: [Date of birth]

Address: [Street, City, State, ZIP]

Phone: [Primary contact number]

Driver's License Number and State: [License number and issuing state]

Prior Medical Certificate Issues (ever denied or issued for <2 years): [Yes / No] — [Brief details if Yes]

Medical Examiner: [Name], [Credentials] — [State license number and state]; National Registry #: [Number]; Clinic: [Clinic name, address, phone]

Driver Health History (Self-Reported)

(Capture driver responses as Yes / No / Not sure exactly as stated. Preserve "Not sure" responses. Use brief narrative only to clarify positive responses.)

• Surgeries: [Yes / No / Not sure] — [Type(s), date(s), complications, residual limitations if Yes]
• Current Medications and Supplements: [Name — dose — frequency — indication for each] (Include over-the-counter and supplements.)

Health History Items (Add brief details only for positive responses.)

• Neurologic
  • Head injury or concussion: [Yes / No / Not sure] — [Details if Yes]
  • Seizure/epilepsy: [Yes / No / Not sure] — [Details if Yes]
  • Fainting/syncope: [Yes / No / Not sure] — [Details if Yes]
  • Dizziness or vertigo: [Yes / No / Not sure] — [Details if Yes]
  • Frequent or severe headaches: [Yes / No / Not sure] — [Details if Yes]
  • Numbness/tingling or weakness: [Yes / No / Not sure] — [Details if Yes]
  • Memory loss or cognitive problems: [Yes / No / Not sure] — [Details if Yes]
  • Stroke/TIA: [Yes / No / Not sure] — [Details if Yes]
• Vision problems: [Yes / No / Not sure] — [Details if Yes]
• Hearing problems: [Yes / No / Not sure] — [Details if Yes]
• Cardiovascular
  • Heart disease: [Yes / No / Not sure] — [Details if Yes]
  • Myocardial infarction: [Yes / No / Not sure] — [Details if Yes]
  • Bypass/angioplasty/stent: [Yes / No / Not sure] — [Details if Yes]
  • Pacemaker/defibrillator: [Yes / No / Not sure] — [Details if Yes]
• Hypertension: [Yes / No / Not sure] — [Details if Yes]
• Respiratory
  • Chronic cough: [Yes / No / Not sure] — [Details if Yes]
  • Shortness of breath: [Yes / No / Not sure] — [Details if Yes]
  • Lung disease: [Yes / No / Not sure] — [Details if Yes]
  • Asthma: [Yes / No / Not sure] — [Details if Yes]
• Renal/urinary problems: [Yes / No / Not sure] — [Details if Yes]
• Gastrointestinal/liver problems: [Yes / No / Not sure] — [Details if Yes]
• Diabetes: [Yes / No / Not sure] — [Type and treatment if Yes]; Insulin-treated: [Yes / No]
• Mental health conditions: [Yes / No / Not sure] — [Details if Yes]
• Musculoskeletal
  • Missing or impaired limb function: [Yes / No / Not sure] — [Details if Yes]
  • Neck/back problems: [Yes / No / Not sure] — [Details if Yes]
  • Joint/muscle/nerve problems: [Yes / No / Not sure] — [Details if Yes]
• Blood clots or bleeding disorders: [Yes / No / Not sure] — [Details if Yes]
• Cancer: [Yes / No / Not sure] — [Details if Yes]
• Chronic infections: [Yes / No / Not sure] — [Details if Yes]
• Sleep concerns
  • Sleep disorder diagnosis: [Yes / No / Not sure] — [Details if Yes]
  • Witnessed apneas: [Yes / No / Not sure]
  • Daytime sleepiness: [Yes / No / Not sure]
  • Loud snoring: [Yes / No / Not sure]
  • Prior sleep study: [Yes / No / Not sure] — [Details if Yes]
• Hospitalizations: [Yes / No / Not sure] — [Reason and dates if Yes]
• Broken bones: [Yes / No / Not sure] — [Details if Yes]
• Substance use
  • Tobacco ever: [Yes / No]; current: [Yes / No] — [Type/amount if current]
  • Current alcohol use: [Yes / No] — [Amount/frequency if Yes]
  • Illegal substance use in past 2 years: [Yes / No]
  • Prior failed drug test or substance dependence: [Yes / No / Not sure] — [Details if Yes]
• Other conditions not listed: [Yes / No] — [Describe if Yes]

Driver Attestation: Driver attests history is accurate and complete. Signature date/time: [Date/time]

Medical Examiner Review

(Document that the driver health history was reviewed with the driver. Include only items explicitly discussed or reviewed.)

• Pertinent positives discussed: [Summary]
• Records reviewed: [List documents with dates] (Specialist letters, diagnostic reports, CPAP compliance summaries, glucometer downloads, etc.)
• Reconciliation notes: [Clarifications or discrepancies resolved between diagnoses and medications, symptoms and findings, or reported events and records]
• Missing required documentation: [List missing items, or "None"] (If missing items preclude determination, route to Determination Pending or Incomplete Examination.)

Testing & Measurements

• Height: [Value with units]
• Weight: [Value with units]
• BMI: [Value] (If calculated)
• Pulse: [Rate] bpm — [Regular / Irregular]
• Blood Pressure (seated): [Initial reading] mmHg; Repeat if elevated: [Repeat reading] mmHg — [Timing/context of repeat]
• Neck circumference: [Value with units] (Include only if measured for OSA risk assessment)

Urinalysis: Specific gravity [Value] | Protein [Value] | Blood [Value] | Sugar [Value] — [Normal / Abnormal]; [Further evaluation recommended and reason if abnormal] (If UA cannot be performed, document reason and mark examination Incomplete.)

Vision:

• Distant visual acuity: Right [Uncorrected / Corrected: value]; Left [Uncorrected / Corrected: value]; Both [Uncorrected / Corrected: value]
• Horizontal field of vision: Right [degrees]; Left [degrees]
• Color recognition (red/green/amber): [Yes / No]
• Monocular vision: [Yes / No]
• Corrective lenses required: [Yes / No]
• Referral to ophthalmology/optometry: [Yes / No]; Documentation received: [Yes / No] (Include only if referral made)

Hearing:

• Method: [Whisper test / Audiometry]; Hearing aid used during test: [Yes / No]
• Results (whisper test): Right [feet]; Left [feet] (Include only if whisper test used)
• Results (audiometry): [Thresholds per ear or pass/fail per FMCSA standard] (Include only if audiometry used)

Additional Testing: (Include only if performed)

• [Test name] — [Result] — [Rationale for obtaining]

Physical Examination

(Use Normal/Abnormal for each system. For abnormal findings, describe specific findings and functional impact on CMV safety. Complete full exam even if a potentially disqualifying condition is identified. If driver refuses to continue, document as Incomplete Examination with reason.)

• General appearance: [Normal / Abnormal] — [Describe if abnormal]
• Skin: [Normal / Abnormal] — [Describe if abnormal]
• Eyes: [Normal / Abnormal] — [Describe if abnormal]
• Ears: [Normal / Abnormal] — [Describe if abnormal]
• Mouth/Throat: [Normal / Abnormal] — [Describe if abnormal]
• Cardiovascular: [Normal / Abnormal] — [Rate, rhythm, murmurs, edema; functional impact if abnormal]
• Lungs/Chest: [Normal / Abnormal] — [Breath sounds, respiratory effort; functional impact if abnormal]
• Abdomen: [Normal / Abnormal] — [Masses, tenderness, organomegaly if abnormal]
• Genitourinary (including hernia exam): [Normal / Abnormal / Deferred] — [Findings or reason deferred]
• Back/Spine: [Normal / Abnormal] — [ROM, tenderness, deformity if abnormal]
• Extremities/Joints: [Normal / Abnormal] — [ROM, strength, deformity; functional impact if abnormal]
• Neurological (including reflexes): [Normal / Abnormal] — [Cranial nerves, strength, sensation, reflexes if abnormal]
• Gait: [Normal / Abnormal] — [Describe if abnormal]
• Vascular system: [Normal / Abnormal] — [Pulses, bruits, varicosities if abnormal]

Medical Qualification Considerations

(Address only conditions relevant to this driver's qualification. Delete any subsections below that do not apply. Do not infer absence of conditions without documented basis. Clearly label any clinical inference from observed data.)

[Other Condition Name]

(Use this format for any qualification-relevant condition not covered by the specific subsections below. Repeat as needed for additional conditions.)

• Pertinent history and corroborating records: [Summary]
• Objective findings: [Summary]
• Current treatment and stability: [Medications/therapies, adherence, side effects]
• CMV safety impact assessment: [Specific risks related to driving]
• Regulatory pathway: [Standard qualification / Exception or variance (specify)]
• Effect on determination: [How this condition influences certification or restrictions]

Hypertension

(Include only if hypertension present or BP elevated)

• BP stage used for certification: [Stage 1 / Stage 2 / Stage 3 per FMCSA criteria]
• Repeat measurement(s): [Values and timing]
• Rationale for certification interval: [Reason for interval selected]

Sleep Apnea Considerations

(Include only if OSA diagnosed or clinical concern for undiagnosed OSA)

• Reported symptoms: [Snoring, daytime sleepiness, witnessed apneas]
• Observed risk factors: [BMI, neck circumference, hypertension, other]
• Clinical reasoning for referral: [Rationale if referral recommended; note FMCSA does not mandate OSA screening]
• Current functional status: [Treatment use/adherence if diagnosed; residual symptoms]

Insulin-Treated Diabetes

(Include only if driver uses insulin)

• MCSA-5870 (treating clinician assessment) received: [Yes / No] — Signature date: [Date]
• Stability and hypoglycemia history: [Driver report and records summary]
• Records reviewed: [Glucometer/CGM downloads, A1c, other]

Vision Exception Pathway

(Include only if driver does not meet vision standards in one or both eyes)

• MCSA-5871 specialist evaluation received: [Yes / No] — Signature date: [Date]
• Exam began within 45 days of specialist signature: [Yes / No]

Medications with Impairment Potential

(Include only if driver takes medications with sedating or impairing effects)

• Risk assessment: [Sedation, cognitive, or motor effects relevant to driving]
• Prescriber input obtained: [Yes / No] — [Summary if obtained]
• Medication timing relative to driving: [Instructions/plan]

Limb Impairment / SPE

(Include only if limb impairment identified)

• Functional capacity observations: [Grip, strength, ROM; ability to perform CMV tasks]
• SPE documentation accompanies driver: [Yes / No] — [Details]

Waivers/Exemptions

(Include only if driver holds or requires a waiver or exemption)

• Type and scope: [Vision / Hearing / Seizure / Other (specify)]
• Documentation present: [Yes / No] — [Details]

Medical Examiner Determination

(Document one determination matching the Certification Basis above. Do not document both Federal and State.)

• Disposition: [Meets standards (2-year certificate) / Meets standards with periodic monitoring / Determination pending / Does not meet standards / Incomplete examination]
• Certification Interval: [3 months / 6 months / 1 year / 2 years] — [Rationale required if shorter than 2 years]
• Restrictions/Conditions for MEC: [List only those that apply: Corrective lenses / Hearing aid / Waiver or exemption (specify) / SPE certificate / Intracity zone / State grandfathering (intrastate only)]
• Determination Rationale: [Brief narrative explaining basis for determination, interval, and any restrictions]

If Determination Pending: [List each missing item] — Return-by date (≤45 days): [Date]

If Does Not Meet Standards: [Plain-language reason] — [Next steps discussed, including applicable exemption/waiver pathways]

Follow-Up & Counseling

(Include only items applicable to this driver.)

• Documents required (if pending): [What, from whom, by when]
• Monitoring during certification interval: [BP follow-up, treatment adherence, labs, device compliance summaries, etc.]
• Safety counseling provided: [Symptoms that could impair driving, medication timing, when to seek evaluation]
• Advice regarding abnormal screening findings: [Recommendations and referrals for non-qualifying conditions identified]
• Shortened interval explanation: [State that interval is for monitoring and does not necessarily indicate future disqualification] (Include only if interval <2 years)

Forms & Reporting

• Forms completed: MER (MCSA-5875) [Yes]; MEC (MCSA-5876) [Yes / No — reason if not issued]
• Attachments received: [List with dates as applicable: MCSA-5870, MCSA-5871, waiver/exemption letters, SPE certificate, other]
• National Registry submission: [Submitted / Scheduled for submission] — [Date]

Signatures

Medical Examiner Signature: [Name, credentials] — Date/time: [Date/time]

Driver Health History Attestation: [Reference signature date/time captured above]

(If information required for determination is missing and cannot be obtained, explicitly document what is missing and why. Route to Determination Pending with deadline or Incomplete Examination as appropriate. Do not assume or infer missing information.)