DOT Physical Examination Form | Efficient Medical Care PC

Driver Information

Last Name ^*

First Name ^*

Middle Initial

Date of Birth ^*

Age

Sex ^*

Male

Female

Home Address ^*

City ^*

State ^*

Zip Code

Phone Number ^*

Email Address

Driving / License Information

Driver License Number ^*

License State ^*

License Expiration Date

Employer / Company Name

Employer Phone

Employer Address

Type of Driving

Type of Commercial Motor Vehicle (CMV) Operated

Combination Vehicle Truck Bus / Motor Coach School Bus Hazardous Materials Passenger (15+ seats) Other

Driving Route

Interstate

Intrastate

Both

Health History

Answer all questions completely and honestly. Falsification of information may result in disqualification from operating a commercial motor vehicle.

Have you ever had, or do you currently have, any of the following? ^*

Cardiovascular

Heart Disease / Attack Angina / Chest Pain Heart Surgery / Stent Pacemaker / Defibrillator High Blood Pressure Blood Clots / DVT / PE

Neurological

Seizures / Epilepsy Stroke / TIA Serious Head / Brain Injury Fainting / Loss of Consciousness Dizziness / Balance Problems Paralysis / Numbness / Weakness

Respiratory

Sleep Apnea Use CPAP / BiPAP Chronic Cough / Shortness of Breath Asthma / COPD / Emphysema Tuberculosis (TB)

Metabolic & Other

Diabetes (any type) Uses Insulin Kidney Disease / Dialysis Liver Disease Cancer Muscular / Neuromuscular Disease

Mental Health & Substance

Mental / Psychiatric Disorder Depression / Anxiety PTSD Alcohol / Substance Use Disorder Failed DOT Drug Test

Eyes / Musculoskeletal / Other

Vision Loss / Eye Disease Hearing Loss Chronic Back / Spine Pain Missing Limb / Amputation Severe Arthritis

Additional Health Conditions / Details

Have you ever been denied a DOT Medical Certificate or issued a limited certificate?

Yes

Current Medications

List ALL medications, supplements, and over-the-counter drugs you currently take. Some medications may affect your ability to safely operate a CMV.

Medication Name

Dose

Frequency

Prescribed For

Sleep & Fatigue

Have you been diagnosed with Sleep Apnea?

Yes

Not Sure

Do you use a CPAP / BiPAP machine?

Yes

Average hours of sleep per night

Less than 5

5–6 hrs

7–8 hrs

More than 8

Do you ever feel excessively sleepy while driving?

Yes

Vision & Hearing

Do you wear glasses or contact lenses?

Glasses

Contact Lenses

Both

Do you wear a hearing aid?

Yes

Physical Measurements

Self-reported — to be verified by examiner during appointment

Height (ft)

Height (in)

Weight (lbs)

Neck Circumference (in)

Driver Certification

Application Summary

Driver Certification (49 CFR 391.43):
I certify that I have carefully read and understand the above instructions, that I was physically examined by the medical examiner named below, and that the information I have furnished above is true and complete to the best of my knowledge and belief, and that I have no physical, mental, or organic condition that would render me unable to operate a commercial motor vehicle safely.

^* I certify that all information provided above is true, accurate, and complete. I understand that falsification of this form is grounds for disqualification.

HIPAA Authorization:
I authorize Efficient Medical Care PC to use and disclose my protected health information to the Federal Motor Carrier Safety Administration (FMCSA) and my employer / prospective employer as required by federal law (49 CFR Part 391).

^* I authorize release of examination results to FMCSA and my employer as required by DOT regulations.

Driver Signature (Type Full Name) ^*

Date ^*

Submitting this form does not replace your in-person DOT Physical Exam. Our office will contact you to confirm your appointment date and time at your preferred location.

Form Submitted Successfully

Thank you! Your DOT Physical pre-exam information has been received. Our FMCSA-certified medical examiner team will contact you within 1 business day to schedule your appointment.

Call (718) 526-2525 Return to Home

Step 1 of 4