DL-171 (06-08) Medical Examination Report FOR COMMERCIAL DRIVER FITNESS DETERMINATION 1. DRIVER’S INFORMATION Driver’s Name (Last, First, Middle) Address Driver completes this section. Social Security No. City, State, Zip Code Work Tel: ( Birthdate M/D/Y Home Tel: ( 2. HEALTH HISTORY Yes No Age ) Sex M F New Certification Date of Exam Recertification Follow Up Driver License No. License Class ) A B C D Other State of Issue Driver completes this section, but medical examiner is encouraged to discuss with driver. Any illness or injury in 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 Yes No 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 Yes No 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 Loss of, or altered consciousness For any YES answer, indicate onset date, diagnosis, treating physician’s name and address, and any current limitation. List all medications (including over-thecounter 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.) American LegalNet, Inc. www.FormsWorkFlow.com TESTING (Medical Examiner completes Section 3 through 7) Name: Last, First, Middle, Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70° peripheral in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner’s Certificate. 3. 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. Applicant can recognize and distinguish among traffic control signals and devices showing standard red, green and amber colors? Yes No Numerical readings must be provided. ACUITY UNCORRECTED CORRECTED HORIZONTAL FIELD OF VISION Right Eye 20/ 20/ Both Eyes 20/ 20/ Left Eye 20/ ° Right Eye 20/ Applicant meets visual acuity requirement only when wearing: Corrective Lenses ° Left Eye ° Complete next line only if vision testing is done by an ophthalmologist or optometrist Date of Examination 4. HEARING Name of Ophthalmologist or Optometrist (print) Monocular Vision: Tel. No. Yes 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 500 Hz, -10 dB for 1,000 Hz, -8.5 dB for 2,000 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. Right Ear Feet 5. BLOOD PRESSURE / PULSE RATE Blood Pressure Systolic Diastolic Driver qualified if < 140/90. Pulse Rate Regular Irregular Record Pulse Rate: Left Ear b) If audiometer is used, record hearing loss in decibels. (acc. to ANSI Z24.5-1951) Feet Right Ear 500 Hz 1000Hz 2000Hz Left Ear 500 Hz 1000Hz Average: Average: 2000Hz Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP. Reading GUIDELINES FOR BLOOD PRESSURE EVALUATION Category Expiration Date 140-159/90-99 Stage 1 1 year 160-179/100-109 Stage 2 One-time certificate for 3 mo. ≥ 180/110 Stage 3 Disqualified 6. LABORATORY AND OTHER TEST FINDINGS Numerical readings must be recorded. Recertification 1 year if < 140/90. One-time certification for 3 mos. if 140-159/90-99. 1 yr. from date of certification exam if