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 Address City, State, Zip Code Work Tel: ( ) Age New Certification Sex M Recertification F Follow-up Driver License No. License Class A B Home Tel: ( ) 2. HEALTH HISTORY Date of Exam State of Issue C D Other Driver completes this section, but medical examiner is encouraged to discuss with driver. Yes No Yes No 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____________________ Fainting, dizziness Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring Loss of, or altered consciousness Regular, frequent alcohol use Narcotic or habit forming drug use Stroke or paralysis Missing or impaired hand, arm, foot, leg, finger, toe Spinal injury or disease Chronic low back pain 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. 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" answers and potential hazards of medications, including over-the-counter medications, while driving. This discussion must be documented below. ) American LegalNet, Inc. www.FormsWorkFlow.com TESTING (Medical Examiner completes Section 3 through 7) Name: 3. Last, First, Middle, Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate. VISION INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified. Numerical readings must be provided. ACUITY UNCORRECTED CORRECTED Right Eye 20/ 20/ Right Eye Left Eye 20/ 20/ Left Eye Both Eyes 20/ 20/ HORIZONTAL FIELD OF VISION Applicant can recognize and distinguish among traffic control sign als and devices showing standard red, green, and amber colors ? Yes No Applicant meets visual acuity requirement only when wearing: Corrective Lenses Monocular Vision: Yes No Complete next line only if vision testing is done by an opthalmologist or optometrist Date of Examination 4. HEARING Name of Ophthalmologist or Optometrist (print) Tel. No. License No./ State of Issue Signature Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB Check if hearing aid used for tests. Check if hearing aid required to meet standard. INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3 frequencies tested and divide by 3. Numerical readings must be recorded. a) Record distance from individual at which forced whispered voice can first be heard. 5. BLOOD PRESSURE/ PULSE RATE Blood Pressure Systolic Diastolic Right Ear Right ear Left Ear \ Feet \ Feet b) If audiometer is used, record hearing loss in decibels. (acc. to ANSI Z24.5-1951) 500 Hz Regular Irregular Record Pulse Rate:____________ 1000 Hz Average: 2000 Hz 500 Hz 1000 Hz 2000 Hz Average: Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP. Reading 140-159/90-99 Category Stage 1 Expiration Date 1 year 160-179/100-109 Stage 2 One-time certificate for 3 months. Recertification 1 year if