Fillable Printable Form DS-874 - Medical Examination Report of Driver - New York

Form DS-874 - Medical Examination Report of Driver - New York

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MEDICAL EXAMINATION REPORT OF DRIVER UNDER ARTICLE 19-A

INSTRUCTIONS TO MEDICAL EXAMINER: The complete standards and instructions for conducting this examination are found in Section 6.10 of the Commissioner’s

Regulations, 15NYCRR6, and can be found at http://www.dmv.ny.gov/art19.htm. They are also available from the driver’s carrier named below or from the Bus Driver Unit. For

New/Initial Examinations and Recertification–review/complete ALL items on the form and sign where indicated on last page. For Follow-up Examinations–complete

ONLY those items which require follow-up information and/or evaluation from a prior examination. Sign the form where indicated. If additional space is required for further

comments and information, use form DS-874C, and attach it to this form.

DRIVER/CARRIER INFORMATION (to be completed by the driver and/or driver’s carrier)

HEALTH HISTORY (to be completed by the driver and reviewed by the medical examiner)

Driver’s Last Name

Street Address

Client/License ID Number

(from Driver License)

State Class of Driver’s License Endorsements Restrictions

Expiration Date

(Driver’s Signature)

(Date)

City State Zip Code

First M.I. Date of Birth (Month/Day/Year) Age Sex

o Male o Female

I certify that the above information and any other information on any accompanying DS-874C, if used, is complete and true. I understand that

inaccurate, false or missing information may invalidate this examination.

DS-874 (6/15)

For any YES answer, the driver should indicate the condition, onset date, diagnosis, treating medical examiner’s name and address, and any current

conditions or comments here: ______________________________________________________________________________________________________

Medical Examiner’s Comments:

Carrier/DBA Name Legal Name (if different) 19-A Business ID Number

Yes No

Yes No Yes No

ooAny illness or injury in the last 5 years?

ooHead/Brain injuries, disorders or illnesses

ooSeizures, epilepsy

ooEye disorders or impaired vision (except corrective lenses)

ooEar disorders, loss of hearing or balance

ooHeart disease or heart attack; other cardiovascular condition

ooHeart surgery (valve replacement/bypass, angioplasty, pacemaker)

ooHigh blood pressure

ooMuscular disease

ooShortness of breath

ooLung disease, emphysema, asthma, chronic bronchitis

ooKidney disease, dialysis

ooLiver disease

ooDigestive problems

ooDiabetes or elevated blood sugar controlled by

(check all that apply): o diet o insulin o other medication

ooIncident of hyperglycemic or hypoglycemic shock

ooLoss of, or altered consciousness

ooFainting, dizziness

ooNervous or psychiatric disorders, e.g., severe depression

ooSleep disorders, pauses in breathing while asleep, daytime

sleepiness, obstructive sleep apnea, loud snoring

ooStroke or paralysis

ooMissing or impaired hand, arm, foot, leg,

finger, toe

ooSpinal injury or disease

ooChronic low back pain

ooRegular, frequent alcohol use

ooNarcotic or habit forming drug use

ooTuberculosis

ooOther ______________________________

___________________________________

www.dmv.ny.gov

Date of Examination

List all medications (including over-the-counter medications) used regularly or recently.

VISION

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.

TESTING (SECTIONS 3 THROUGH 8 TO BE COMPLETED BY THE MEDICAL EXAMINER)

Numerical readings must be provided.

Applicant can recognize and distinguish among traffic control signals and

devices showing standard red, green, and amber colors.

o Yes o No

Applicant meets visual acuity requirement only when wearing corrective

lenses.

o Yes o No Monocular Vision. o Yes o No

ACUITY UNCORRECTED CORRECTED

FIELD OF VISION

Right Eye 20/ 20/ Right Eye °

Left Eye 20/ 20/ Left Eye °

Both Eyes 20/ 20/

Date of Examination

(Signature of Examiner)

License Number/State of Issue

Name of Ophthalmologist or Optometrist (print) Telephone Number

Complete next two lines only if vision testing is done by an ophthalmologist or optometrist.

1) Systolic/Diastolic

Blood Pressure

Readings

2) Systolic/Diastolic

Pulse Rate:

Record Pulse Rate:

______________

o Regular o Irregular

BLOOD PRESSURE/PULSE RATE Standard: If the blood pressure is consistently above 160/90 mm. Hg., further testing may be necessary to determine

whether the driver is qualified to operate a bus. Numerical reading must be recorded. Medical Examiner should take at least two readings to confirm BP.

Additional comments/medications on attached DS-874C

500Hz 1000 Hz 2000 Hz

Average:

Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any

underlying medical problem. Other Testing (Describe and record):

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

o Check if hearing aid used for tests. o Check if hearing aid required to meet standard.

a) Record distance in feet from individual at which forced

whispered voice can first be heard.

Right ear \Feet

Left ear \Feet

b) If audiometer is used, record hearing loss in decibels.(acc. to ANSI Z24.5-1951)

500Hz 1000 Hz 2000 Hz

Right Ear Left Ear

URINE SPECIMEN

SP. GR PROTEIN BLOOD SUGAR

DS-874 (6/15)

HEARING

LABORATORY AND OTHER TEST FINDINGS -

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PHYSICAL

EXAMINATION (to be completed by the medical examiner) -

BODY SYSTEM CHECK FOR: Yes* No

1. General appearance Marked overweight, tremor, signs of alcoholism,

problem drinking, or drug abuse . . . . . . . . . . . . . . . . . . . . . . . . . . oo

2. Eyes Pupillary equality, reaction to light accommodation, ocular

motility, ocular muscle imbalance extraocular movement,

nystagmus, exophthalmos. Ask about retinopathy, cataracts,

aphakia, glaucoma, macular degeneration and refer to a

specialist if appropriate . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . oo

3. Ears Scarring of tympanic membrane, occlusion of external canal,

perforated eardrums . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . oo

4. Mouth and Throat Irremediable deformities likely to interfere with breathing or

swallowing. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . oo

5. Heart Murmurs, extra sounds, enlarged heart, pacemaker,

implantable defibrillator. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . oo

6. Lungs and chest,

not including

breast examination

BODY SYSTEM CHECK FOR: Yes* No

7. Abdomen and Viscera Enlarged liver, enlarged spleen, masses, bruits, hernia,

significant abdominal wall muscle weakness . . . . . . . . . . . o o

8. Vascular System Abnormal pulse and amplitude, carotid or arterial bruits,

varicose veins . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

9. Genito-urinary System Hernias. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

10. Extremities- Limb

impaired.

11. Spine, other Previous surgery, deformities, limitation of motion,

musculoskeletal tenderness . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o o

12. Neurological Impaired equilibrium, coordination or speech pattern;

asymmetric deep tendon reflexes, sensory or positional

abnormalities, abnormal patellar and Babinski reflexes, ataxia. o o

Abnormal chest wall expansion, abnormal respiratory rate,

abnormal breath sounds including wheezes or alveolar rales,

impaired respiratory function, cyanosis. Abnormal findings

on physical exam may require further testing such as

pulmonary tests and/ or xray of chest . . . . . . . . . . . . . . . . . . . . . . . oo

Loss or impairment of leg, foot, toe, arm, hand, finger,

perceptible limp, deformities, atrophy, weakness,

paralysis, clubbing, edema, hypotonia. Insufficient

grasp and prehension in upper limb to maintain steering

wheel grip. Insufficient mobility and strength in lower

limb to operate pedals properly. . . . . . . . . . . . . . . . . . . . . . o o

* MEDICAL EXAMINER’S COMMENTS:

The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to

treatment. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the

necessary steps to correct the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.

Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect

the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been

compensated for.

Height __________ (in.) Weight __________ (lbs.)

MEDICAL EXAMINER’S CERTIFICATION:

o New/Initial Certification o Recertification o Follow-Up

o Qualified only when wearing corrective/contact lenses.

o Qualified - Certification required every six months for diabetic condition.

o Qualified only when wearing a hearing aid.

o Qualified only by use of prosthetic devices or equipment modifications.

Description/Type: _____________________________________________

o Qualified, other: _______________________________________________

I certify that I have examined (Print Driver’s Full Name)__________________________________________________________ in accordance with the Commissioner’s

Regulations and with knowledge of the driver’s dutie

s. In accordance with Commissioner’s Regulation 6.10, I find:

o the person named above is physically or medically qualified.

o the person named above IS NOT physically or medically qualified because____________________________________________________________

o the person named above is physically or medically qualified with Restrictions and/or Follow-up as detailed below:

REMARKS:

Print name and check title of:

o Examining Physician

o Nurse Practitioner

o Physician Assistant

o Advanced Practice Nurse*

(who is not a Nurse Practitioner)

Signature of Examiner:

Address of Examiner:

Date:

License or Certificate No./Issuing State

}

Driver’s License/Client ID #_________________________

Driver’s Name: Last _________________________________________ First __________________________ MI _____

* If the examination is conducted by an Advanced Practice Nurse, who is not a Nurse Practitioner, the Supervising Physician must certify as follows:

I certify that the individual who conducted the above examination was acting under my direction and supervision and, if applicable, in accordance

with a written practice or protocol agreement.

(Name of Supervising Physician)

(Signature of Supervising Physician)

THE CARRIER MUST KEEP THE ORIGINAL EXAMINATION REPORT (NOT A PHOTOCOPY) IN THE EMPLOYEE’S 19-A FILE