High Blood Pressure:
Yes/No Yes No

Diabetes:
Yes/No Yes No

Heart Disease:
Yes/No Yes No

Seizures:
Yes/No Yes No

Hearing/Vision Problems:
Yes/No Yes No

Sleep Apnea:
Yes/No Yes No

Other Chronic Conditions:

BackNext

Blood Pressure:

Pulse:

Height:

Weight:

BMI:

Vision Test:
Select Vision Test Result Normal Impaired

Left Eye Vision:

Right Eye Vision:

Corrected Vision (if applicable):

Color Vision:
Normal/Abnormal Normal Abnormal

Hearing Test (whisper test or audiometry results):

BackNext

Head and Neck:

Lungs and Chest:

Heart:

Abdomen:

Extremities (Arms and Legs):

Spine and Back:

Neurological:

BackNext

Is the driver on any medication that may impair ability to drive?
Yes/No Yes No

Any history of seizure, fainting, or dizziness?
Yes/No Yes No

Any history of substance abuse or disqualifying medical conditions?
Yes/No Yes No

Does the driver meet the physical and mental requirements for safe driving?
Yes/No Yes No

Is the driver medically qualified?
Yes/No Yes No

If No, state reasons and recommendations for treatment or further evaluation:

Certification Expiration Date:

BackNext

Physician’s Signature:

Date of Examination:

Physician’s License Number:

Facility Name:

Facility Contact Information:

Print Form

Submit

Back