Fillable Printable Medical Examination Report for Commercial Driver Fitness Determination
Fillable Printable Medical Examination Report for Commercial Driver Fitness Determination
Medical Examination Report for Commercial Driver Fitness Determination
1.
DRIVER'S INFORMATION
Driver's Name (Last, First, Middle) Social Security No.
Birthdate
M / D / Y
Age
Sex
M
F
New Certification
Recertification
Follow-up
Date of Exam
AddressCity, State, Zip Code Work Tel: ( )
Home Tel: ( )
Driver License No.
License Class
A C
B D
Other
State of Issue
2.
HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver.
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
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
Loss of, or altered consciousness
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
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.
Medical Examination Report
FOR COMMERCIAL DRIVER FITNESS DETERMINATION
649-F (6045)
Driver completes this section
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. )
ACUITYUNCORRECTEDCORRECTED
HORIZONTAL FIELD OF VISION
Right Eye 20/ 20/ Right Eye
Left Eye 20/ 20/ Left Eye
Both Eyes 20/ 20/
Right Ear Left Ear
b) If audiometer is used, record hearing loss in
decibels. (acc. to ANSI Z24.5-1951)
500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz
Average:
Average:
5. BLOOD PRESSURE/ PULSE RATE
ReadingCategoryExpiration DateRecertification
140-159/90-99 Stage 1 1 year 1 year if <140/90.
One-time certificate for 3 months if
141-159/91-99.
160-179/100-109 Stage 2 One-time certificate for 3 months. 1 year from date of exam if <140/90
>180/110 Stage 3 6 months from date of exam if <140/906 months if < 140/90
URINE SPECIMEN
SP. GR. PROTEIN BLOOD SUGAR
TESTING (Medical Examiner completes Section 3 through 7)
Name: Last, First, Middle,
3.
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.
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.
Applicant can recognize and distinguish among traffic control
Yes
sign als and devices showing standard red, green, and amber colors
?
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 Name of Ophthalmologist or Optometrist (print) Tel. No.License No./ State of IssueSignature
4.
HEARING
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.
Right ear
\
Feet
Left Ear
\ Feet
Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.
Blood
Pressure
SystolicDiastolic
Driver qualified if <140/90.
Pulse Rate:Regular
Irregular
Record Pulse Rate:
6. LABORATORY AND OTHER TEST FINDINGS
Numerical readings must be recorded
.
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)
7.
PHYSICAL EXAMINATION
Height: (in.) Weight:(lbs.) Name: Last, First,Middle,
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 bodysystem 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.
See Instructions to the Medical Examinerfor guidance.
BODY SYSTEM
1. General Appearance
2. Eyes
3. Ears
4. Mouth and Throat
5. Heart
6. Lungs and chest,
not including breast
examination
CHECK FOR:
Marked overweight, tremor, signs of alcoholism, problem
drinking, or drug abuse.
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.
Scarring of tympanic membrane, occlusion of external canal,
perforated eardrums.
Irremediable deformities likely to interfere with breathing or
swallowing.
Murmurs, extra sounds, enlarged heart, pacemaker,
implantable defibrillator.
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.
YES*
NO
BODY SYSTEM
7. Abdomen and Viscera
8. Vascular System
9. Genito-urinary System
10. Extremities- Limb
impaired. Driver may
be subject to SPE
certificate if otherwise
qualified.
11. Spine, other
musculoskeletal
12. Neurological
CHECK FOR:
YES* NO
Enlarged liver, enlarged spleen, masses, bruits,
hernia, significant abdominal wall muscle
weakness.
Abnormal pulse and amplitude, cartoid or
arterial bruits, varicose veins.
Hernias.
Loss or impairment of leg, foot, toe, arm, hand,
finger, Perceptible limp, deformities, atrophy,
weakness, paralysis, clubbing, edema,
hypotonia. Insufficicent grasp and prehension
in upper limb to maintain steering wheel grip.
Insufficient mobility and strength in lower limb
to operate pedals properly.
Previous surgery, deformities, limitation of
motion, tenderness.
Impaired equilibrium, coordination or speech
pattern; asymmetric deep tendon reflexes,
sensory or positional abnormalities, abnormal
patellar and Babinki's reflexes, ataxia.
*COMMENTS:
Note certification status here. See Instructions to the Medical Examiner for guidance.
Meets standards in 49 CFR 391.41; qualifies for 2 year certificate
Does not meet standards
Meets standards, but periodic monitoring required due to .
Driver qualified only for: 3 months 6 months 1 year Other
Temporarily disqualified due to (condition or medication):
Return to medical examiner's office for follow up on
Wearing corrective lense
Wearing hearing aid
Accompanied by a waiver/ exemption. Driver must present
exemption at time of certification.
Skill Performanc e Evaluation (SPE) Certificate
Driving withi n an exempt intracity zone (See 49 CFR 391.62)
Qualified by operation of 49 CFR 391.64
Medical Examiner's signature
Medical Examiner's name
Address
Telephone Number
If meets standards, complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h). (Driver must carry certificate when operating a commercial vehicle.)
49 CFR 391.41 Physical Qualifications for Drivers
THE DRIVER'S ROLE
Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Some of the main types of
drivers include the following: turn around or short relay (drivers return to their home base each evening); long relay (drivers drive 9-11 hours and then have at least a 10-hour off-
duty period), straight through haul (cross country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and 5-hour rest periods.)
The following factors may be involved in a driver's performance of duties: abrupt schedule changes and rotating work schedules, which may result in irregular sleep patterns and
a driver beginning a trip in a fatigued condition; long hours; extended time away from family and friends, which may result in lack of social support; tight pickup and delivery
schedules, with irregularity in work, rest, and eating patterns, adverse road, weather and traffic conditions, which may cause delays and lead to hurriedly loading or unloading
cargo in order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in temperature. Transporting passengers or hazardous
materials may add to the demands on the commercial driver.
There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling trailer(s) from
the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs. of freight after sitting for a long period of time without any
stretching period); inspecting the operating condition of tractor and/or trailer(s) before, during and after delivery of cargo; lifting, installing, and removing heavy tire chains; and,
lifting heavy tarpaulins to cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a crouching position to inspect the underside
of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s).
In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, the judgment skills to make quick decisions, when necessary, and the
manipulative skills to control an oversize steering wheel, shift gears using a manual transmission, and maneuver a vehicle in crowded areas.
§391.41 PHYSICAL QUALIFICATIONS FOR
DRIVERS
(a)
person shall not drive a commercial motor vehicle
unless he is physically qualified to do so and, except as
provided in §391.67, has on his person the original, or a
photographic copy, of a medical examiner's certificate that
he is physically qualified to drive a commercial motor
vehicle.
(b)
person is physically qualified to drive a motor vehicle if
that person:
(1)
Has no loss of a foot, a leg, a hand, or an arm, or has
been granted a Skill Performance Evaluation (SPE)
Certificate (formerly Limb Waiver Program) pursuant to
§391.49.
(2)
Has no impairment of: (i) A hand or finger which
interferes with prehension or power grasping; or (ii) An
arm, foot, or leg which interferes with the ability to perform
normal tasks associated with operating a commercial motor
vehicle; or any other significant limb defect or limitation
which interferes with the ability to perform normal tasks
associated with operating a commercial motor vehicle; or
has been granted a SPE Certificate pursuant to §391.49.
(3)
Has no established medical history or clinical diagnosis
of diabetes mellitus currently requiring insulin for control;
(4)
Has no current clinical diagnosis of myocardial
infarction, angina pectoris, coronary insufficiency,
thrombosis, or any other cardiovascular disease of a variety
known to be accompanied by syncope, dyspnea, collapse,
or congestive cardiac failure.
(5)
Has no established medical history or clinical diagnosis
of a respiratory dysfunction likely to interfere with his
ability to control and drive a commercial motor vehicle
safely.
(6)
Has no current clinical diagnosis of high blood pressure
likely to interfere with his ability to operate a commercial
motor vehicle safely.
(7)
Has no established medical history or clinical diagnosis
of rheumatic, arthritic, orthopedic, muscular,
neuromuscular, or vascular disease which interferes with
his ability to control and operate a commercial motor
vehicle safely.
(8)
Has no established medical history or clinical diagnosis
of epilepsy or any other condition which is likely to cause
loss of consciousness or any loss of ability to control a
commercial motor vehicle;
(9)
Has no mental, nervous, organic, or functional disease
or psychiatric disorder likely to interfere with his ability to
drive a commercial motor vehicle safely;
(10)
Has distant visual acuity of at least 20/40 (Snellen) in
each eye without corrective lenses or visual acuity
separately corrected to 20/40 (Snellen) or better with
corrective lenses, distant binocular acuity of at least 20/40
(Snellen) in both eyes with or without corrective lenses,
field of vision of at least 70degrees in the horizontal
meridian in each eye, and the ability to recognize the colors
of traffic signals and devices showing standard red, green
and amber;
(11)
First perceives a forced whispered voice in the better
ear not less than 5 feet with or without the use of a hearing
aid, or, if tested by use of an audiometric device, does not
have an average hearing loss in the better ear greater than
40 decibels at 500 Hz, 1,000 Hz and 2,000 Hz with or
without a hearing device when the audiometric device is
calibrated to the American National Standard (formerly
ASA Standard) Z24.5-1951;
(12)(i) Does not use any drug or substance identified in 21
CFR 1308.11 Schedule I, an amphetamine, a narcotic, or
other habit-forming drug.
(ii) Does not use any non-Schedule I drug or substance that
is identified in the other Schedules in 21 part 1308 except
when the use is prescribed by a licensed medical
practitioner, as defined in § 382.107, who is familiar with
the driver’s medical history and has advised the driver that
the substance will not adversely affect the driver’s ability to
safely operate a commercial motor vehicle.
(13) Has no current clinical diagnosis of
alcoholism.
INSTRUCTIONS TO THE MEDICAL EXAMINER
General Information
The purpose of this examination is to determine a driver's physical
qualification to operate a commercial motor vehicle (CMV) in interstate
commerce according to the requirements in 49 CFR 391.41-49. Therefore,
the medical examiner must be knowledgeable of these requirements and
Loss of Limb:
§391.41(b)(1)
Federal Motor Carrier Safety Regulations
-Advisory Criteria-
Diabetes
§391.41(b)(3)
A person is physically qualified to drive a commercial motor
guidelines developed by the FMCSA to assist the medical examiner in
making the qualification determination. The medical examiner should be
familiar with the driver's responsibilities and work environment and is
referred to the section on the form, The Driver's Role.
In addition to reviewing the Health Historysection with the driver and
conducting the physical examination, the medical examiner should discuss
common prescriptions and over-the-counter medications relative to the side
effects and hazards of these medications while driving. Educate the driver
to read warning labels on all medications. History of certain conditions may
be cause for rejection, particularlyif required by regulation, or mayindicate
the need for additional laboratorytests or more stringent examination
perhaps bya medical specialist. These decisions are usually made by the
medical examiner in light of the driver's job responsibilities, work schedule
and potential for the conditions to render the driver unsafe.
Medical conditions should be recorded even if they are not cause for
denial, and they should be discussed with the driver to encourage
appropriate remedial care. This advice is especially needed when a
condition, if neglected, could develop into a serious illness that could affect
driving.
If the medical examiner determines that the driver is fit to drive and is
also able to perform non-driving responsibilities as maybe required, the
medical examiner signs the medical certificate which the driver must carry
with his/her license.
The certificate must be dated. Under current
regulations, the certificate is valid for two years, unless the driver has
a medical condition that does not prohibit driving but does require
more frequent monitoring. In such situations, the medical certificate
should be issued for a shorter length of time. The physical examination
should be done carefully and at least as complete as is indicated by the
attached form. Contact the FMCSA at (202) 366-1790 for further
information (a vision exemption, qualifying drivers under 49 CFR 391.64,
etc.).
Interpretation of Medical Standards
Since the issuance of the regulations for physical qualifications of
commercial drivers, the Federal Motor Carrier SafetyAdministration
(FMCSA) has published recommendations called Advisory Criteria to help
medical examiners in determining whether a driver meets the physical
qualifications for commercial driving. These recommendations have been
condensed to provide information to medical examiners that (1) is directly
relevant to the physical examination and (2) is not already included in the
medical examination form. The specific regulation is printed in italics and
it's reference by section is highlighted.
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no loss of a foot, leg, hand or an arm, or has been
granted a Skill Performance Evaluation (SPE) Certificate
pursuant to Section 391.49.
Limb Impairment:
§391.41(b)(2)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no impairment of: (i) A hand or finger which interferes
with prehension or power grasping; or (ii) An arm, foot, or leg
which interferes with the ability to perform normal tasks
associated with operating a commercial motor vehicle; or (iii)
Any other significant limb defect or limitation which interferes
with the ability to perform normal tasks associated with
operating a commercial motor vehicle; or (iv) Has been
granted a Skill Performance Evaluation (SPE) Certificate
pursuant to Section 391.49.
A person who suffers loss of a foot, leg, hand or arm or
whose limb impairment in any way interferes with the safe
performance of normal tasks associated with operating a
commercial motor vehicle is subject to the Skill Performance
Evaluation Certification Program pursuant to section
391.49, assuming the person is otherwise qualified.
With the advancement of technology, medical aids and
equipment modifications have been developed to compensate
for certain disabilities. The SPE Certification Program
(formerly the Limb Waiver Program) was designed to allow
persons with the loss of a foot or limb or with functional
impairment to qualify under the Federal Motor Carrier Safety
Regulations (FMCSRs) by use of prosthetic devices or
equipment modifications which enable them to safely
operate a commercial motor vehicle. Since there are no medical
aids equivalent to the original body or limb, certain risks are
still present, and thus restrictions may be included on individual
SPE certificates when a State Director for the FMCSA determines
they are necessary to be consistent with safety and public
interest.
If the driver is found otherwise medically qualified
(391.41(b)(3) through (13)), the medical examiner must check
on the medical certificate that the driver is qualified only if
accompanied by a SPE certificate. The driver and the employing
motor carrier are subject to appropriate penalty if the driver
operates a motor vehicle in interstate or foreign commerce
without a curent SPE certificate for his/her physical disability.
vehicle if that person:
Has no established medical history or clinical diagnosis of
diabetes mellitus currently requiring insulin for control.
Diabetes mellitus is a disease which, on occasion, can
result in a loss of consciousness or disorientation in time
and space. Individuals who require insulin for control have
conditions which can get out of control by the use of too
much or too little insulin, or food intake not consistent with
the insulin dosage. Incapacitation may occur from
symptoms of hyperglycemic or hypoglycemic reactions
(drowsiness, semiconsciousness, diabetic coma or insulin
shock).
The administration of insulin is, within itself, a
complicated process requiring insulin, syringe, needle,
alcohol sponge and a sterile technique. Factors related to
long-haul commercial motor vehicle operations, such as
fatigue, lack of sleep, poor diet, emotional conditions,
stress, and concomitant illness, compound the dangers,
the FMCSA has consistently held that a diabetic who uses
insulin for control does not meet the minimum physical
requirements of the FMCSRs.
Hypoglycemic drugs, taken orally, are sometimes
prescribed for diabetic individuals to help stimulate natural
body production of insulin. If the condition can be
controlled by the use of oral medication and diet, then an
individual may be qualified under the present rule. CMV
drivers who do not meet the Federal diabetes standard
may call (202) 366-1790 for an application for a diabetes
exemption.
(See Conference Report on Diabetic Disorders and
Commercial Drivers and Insulin-Using Commercial Motor
Vehicle Drivers at:
//www.fmcsa.dot.gov/rulesregs/medreports.htm)
Cardiovascular Condition
§391.41(b)(4)
A person is physically qualified to drive a commercial
motor vehicle if that person:
Has no current clinical diagnosis of myocardial infarction,
angina pectoris, coronary insufficiency, thrombosis or any
other cardiovascular disease of a variety known to be
accompanied by syncope, dyspnea, collapse or congestive
cardiac failure.
The term "has no current clinical diagnosis of" is
specifically designed to encompass: "a clinical diagnosis
of" (1) a current cardiovascular condition, or (2) a
cardiovascular condition which has not fully stabilized
regardless of the time limit The term "known to be
accompanied by" is designed to include a clinical diagnosis of
a cardiovascular disease (1) which is accompanied by
symptoms of syncope, dyspnea, collapse or congestive
cardiac failure; and/or (2) which is likely to cause syncope,
dyspnea, collapse or congestive cardiac failure.
It is the intent of the FMCSRs to render unqualified, a
driver who has a current cardiovascular disease which is
accompanied by and/or likely to cause symptoms of syncope,
dyspnea, collapse, or congestive cardiac failure.
However, the subjective decision of whether the nature and
severity of an individual's condition will likely cause
symptoms of cardiovascular insufficiency is on an individual
basis and qualification rests with the medical examiner and
the motor carrier. In those cases where there is an
occurrence of cardiovascular insufficiency (myocardial
infarction, thrombosis, etc.), it is suggested before a driver is
certified that he or she have a normal resting and stress
electrocardiogram (ECG), no residual complications and no
physical limitations, and is taking no medication likely to
interfere with safe driving.
Coronary artery bypass surgery and pacemaker
implantation are remedial procedures and thus, not
unqualifying. Implantable cardioverter defibrillators are
disqualifying due to risk of syncope. Coumadin is a medical
treatment which can improve the health and safety of the
driver and should not, by its use, medically disqualify the
commercial driver. The emphasis should be on the underlying
medical condition(s) which require treatment and the general
health of the driver. The FMCSA should be contacted at (202)
366-1790 for additional recommendations regarding the
physical qualification of drivers on coumadin.
(See Cardiovasular AdvisoryPanel Guidelines for the
Medical examination of Commercial Motor Vehicle Drivers
at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)
Respiratory Dysfunction
§391.41(b)(5)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no established medical history or clinical diagnosis of a
respiratory dysfunction likely to interfere with ability to control
and drive a commercial motor vehicle safely.
Since a driver must be alert at all times, any change in
his or her mental state is in direct conflict with highway safety.
Even the slightest impairment in respiratory function under
emergency conditions (when greater oxygen supply is
necessary for performance) may be detrimental to safe
driving.
There are many conditions that interfere with oxygen
exchange and may result in incapacitation, including
emphysema, chronic asthma, carcinoma, tuberculosis,
chronic bronchitis and sleep apnea. If the medical examiner
detects a respiratory dysfunction, that in any way is likely to
interfere with the driver's ability to safely control and drive a
commercial motor vehicle, the driver must be referred to a
specialist for further evaluation and therapy. Anticoagulation
therapy for deep vein thrombosis and/or pulmonary
thromboembolism is not unqualifying once optimumdose is
achieved, provided lower extremity venous examinations
remain normal and the treating physician gives a favorable
recommendation.
(See Conference on Pulmonary/Respiratory Disorders and
Commercial Drivers at:
//www.fmcsa.dot.gov/rulesregs/medreports.htm
Hypertension
§391.41(b)(6)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no current clinical diagnosis of high blood pressure likely
to interfere with ability to operate a commercial motor vehicle
safely.
Hypertension alone is unlikely to cause sudden
collapse; however, the likelihood increases when target organ
damage, particularly cerebral vascular disease, is present.
This regulatory criteria is based on FMCSA's Cardiovascular
Advisory Guidelines for the Examination of CMV Drivers,
which used the Sixth Report of the Joint National Committee
on Detection, Evaluation, and Treatment of High Blood
Pressure (1997).
Stage 1 hypertension corresponds to a systolic BP of
140-159 mmHg and/or a diastolic BP of 90-99 mmHg. The
driver with a BP in this range is at low risk for hypertension-
related acute incapacitation and may be medically certified to
drive for a one-year period. Certification examinations should
be done annually thereafter and should be at or less than
140/90. If less than 160/100, certification may be extended
one time for 3 months.
A blood pressure of 160-179 systolic and/or 100-109
diastolic is considered Stage 2 hypertension, and the driver is
not necessarily unqualified during evaluation and institution of
treatment. The driver is given a one time certification of three
months to reduce his or her blood pressure to less than or
equal to 140/90. A blood pressure in this range is an absolute
indication for anti-hypertensive drug therapy. Provided
treatment is well tolerated and the driver demonstrates a BP
value of 140/90 or less, he or she may be certified for one
year from date of the initial exam. The driver is certified
annually thereafter.
A blood pressure at or greater than 180 (systolic) and
110 (diastolic) is considered Stage 3, high risk for an acute
BP-related event. The driver may not be qualified, even
temporarily, until reduced to 140/90 or less and treatment is
well tolerated. The driver may be certified for 6 months and
biannually (every 6 months) thereafter if at recheck BP is
140/90 or less.
Annual recertification is recommended if the medical
examiner does not know the severity of hypertension prior to
treatment.
An elevated blood pressure finding should be confirmed
by at least two subsequent measurements on different days.
Treatment includes nonpharmacologic and
pharmacologic modalities as well as counseling to reduce
other risk factors. Most antihypertensive medications also
have side effects, the importance of which must be judged on
an individual basis. Individuals must be alerted to the hazards
of these medications while driving. Side effects of
somnolence or syncope are particulary undesirable in
commercial drivers.
Secondary hypertension is based on the above stages.
Evaluation is warranted if patient is persistently hypertensive
on maximal or near-maximal doses of 2-3 pharmacologic
agents. Some causes of secondary hypertension may be
amenable to surgical intervention or specific pharmacologic
disease.
(See Cardiovascular Advisory Panel Guidelines for the
Medical Examination of Commercial Motor Vehicle Drivers at:
//www.fmcsa.dot.gov/rulesregs/medreports.htm)
Rheumatic, Arthritic, Orthopedic, Muscular,
Neuromuscular or Vascular Disease §391.41(b)(7)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no established medical history or clinical diagnosis of
rheumatic, arthritic, orthopedic, muscular, neuromuscular or
vascular disease which interferes with the ability to control
and operate a commercial motor vehicle safely.
Certain diseases are known to have acute episodes of
transient muscle weakness, poor muscular coordination
(ataxia), abnormal sensations (paresthesia), decreased
muscular tone (hypotonia), visual disturbances and pain
which may be suddenly incapacitating. With each recurring
episode, these symptoms may become more pronounced
and remain for longer periods of time. Other diseases have
more insidious onsets and display symptoms of muscle
wasting (atrophy), swelling and paresthesia which may not
suddenly incapacitate a person but may restrict his/her
movements and eventually interfere with the ability to safely
operate a motor vehicle. In many instances these diseases
are degenerative in nature or may result in deterioration of
the involved area.
Once the individual has been diagnosed as having a
rheumatic, arthritic, orthopedic, muscular, neuromuscular or
vascular disease, then he/she has an established history of
that disease. The physician, when examining an individual,
should consider the following: (1) the nature and severity of
the individual's condition (such as sensory loss or loss of
strength); (2) the degree of limitation present (such as range
of motion); (3) the likelihood of progressive limitation (not
always present initially but may manifest itself over time); and
(4) the likelihood of sudden incapacitation. If severe
functional impairment exists, the driver does not qualify. In
cases where more frequent monitoring is required, a
certificate for a shorter period of time may be issued. (See
Conference on Neurological Disorders and Commercial
Drivers at:
//www.fmcsa.dot.gov/rulesregs/medreports.htm)
Epilepsy
§391.41(b)(8)
A person is physically qualified to drive a commercial motor vehicle
if that person:
Has no established medical history or clinical diagnosis of epilepsy
or any other condition which is likely to cause loss of
consciousness or any loss of ability to control a motor vehicle.
Epilepsy is a chronic functional disease characterized by
seizures or episodes that occur without warning, resulting in loss of
voluntary control which may lead to loss of consciousness and/or
seizures. Therefore, the following drivers cannot be qualified: (1) a
driver who has a medical history of epilepsy; (2) a driver who has a
current clinical diagnosis of epilepsy; or (3) a driver who is taking
antiseizure medication.
If an individual has had a sudden episode of a nonepileptic
seizure or loss of consciousness of unknown cause which did not
require antiseizure medication, the decision as to whether that
person's condition will likely cause loss of consciousness or loss of
ability to control a motor vehicle is made on an individual basis by
the medical examiner in consultation with the treating physician.
Before certification is considered, it is suggested that a 6 month
waiting period elapse from the time of the episode. Following the
waiting period, it is suggested that the individual have a complete
neurological examination. If the results of the examination are
negative and antiseizure medication is not required, then the driver
may be qualified.
In those individual cases where a driver has a seizure or an
episode of loss of consciousness that resulted from a known
medical condition (e.g., drug reaction, high temperature, acute
infectious disease, dehydration or acute metabolic disturbance),
certification should be deferred until the driver has fully recovered
from that condition and has no existing residual complications, and
not taking antiseizure medication.
Drivers with a history of epilepsy/seizures off antiseizure
medicationand seizure-free for 10 years may be qualified to drive
a CMV in interstate commerce. Interstate drivers with a history of
a single unprovoked seizure may be qualified to drive a CMV in
interstate commerce if seizure-free and off antiseizure medication
for a 5-year period or more.
(See Conference on Neurological Disorders and Commercial
Drivers at:
//www.fmcsa.dot.gov/rulesregs/medreports.htm)
Mental Disorders
§391.41(b)(9)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has no mental, nervous, organic or functional disease or
psychiatric disorder likely to interfere with ability to drive a motor
vehicle safely.
Emotional or adjustment problems contribute directly to an
individual's level of memory, reasoning, attention, and judgment.
These problems often underlie physical disorders. A variety of
functional disorders can cause drowsiness, dizziness,
confusion, weakness or paralysis that may lead to
incoordination, inattention, loss of functional control and
susceptibility to accidents while driving. Physical fatigue,
headache, impaired coordination, recurring physical ailments
and chronic "nagging" pain may be present to such a degree
that certification for commercial driving is inadvisable. Somatic
and psychosomatic complaints should be thoroughly examined
when determining an individual's overall fitness to drive.
Disorders of a periodically incapacitating nature, even in the
early stages of development, may warrant disqualification.
Many bus and truck drivers have documented that "nervous
trouble" related to neurotic, personality, or emotional or
adjustment problems is responsible for a significant fraction of
their preventable accidents. The degree to which an individual
is able to appreciate, evaluate and adequately respond to
environmental strain and emotional stress is critical when
assessing an individual's mental alertness and flexibility to cope
with the stresses of commercial motor vehicle driving.
When examining the driver, it should be kept in mind that
individuals who live under chronic emotional upsets may have
deeply ingrained maladaptive or erratic behavior patterns.
Excessively antagonistic, instinctive, impulsive, openly
aggressive, paranoid or severely depressed behavior greatly
interfere with the driver's ability to drive safely. Those
individuals who are highly susceptible to frequent states of
emotional instability (schizophrenia, affective psychoses,
paranoia, anxiety or depressive neuroses) may warrant
disqualification. Careful consideration should be given to the
side effects and interactions of medications in the overall
qualification determination. See Psychiatric Conference Report
for specific recommendations on the use of medications and
potential hazards for driving.
(See Conference on Psychiatric Disorders and Commercial
Drivers at:
http://www.fmcsa.dot.gov/rulesregs/medreports.htm)
Vision
§391.41(b)(10)
A person is physically qualified to drive a commercial motor
vehicle if that person:
Has distant visual acuity of at least 20/40 (Snellen) in each eye
with or without corrective lenses or visual acuity separately
corrected to 20/40 (Snellen) or better with corrective lenses,
distant binocular acuity of at least 20/40 (Snellen) in both eyes
with or without corrective lenses, field of vision of at least 70
degrees in the horizontal meridian in each eye, and the ability to
recognize the colors of traffic signals and devices showing
standard red, green, and amber.
The term "ability to recognize the colors of" is interpreted to
mean if a person can recognize and distinguish among traffic
control signals and devices showing standard red, green and
amber, he or she meets the minimum standard, even though he
or she may have some type of color perception deficiency. If
certain color perception tests are administered, (such as
Ishihara, Pseudoisochromatic, Yarn) and doubtful findings are
discovered, a controlled test using signal red, green and amber
may be employed to determine the driver's ability to recognize
these colors.
Contact lenses are permissible if there is sufficient evidence
to indicate that the driver has good tolerance and is well
adapted to their use. Use of a contact lens in one eye for
distance visual acuity and another lens in the other eye for near
vision is not acceptable, nor telescopic lenses acceptable for
the driving of commercial motor vehicles.
If an individual meets the criteria by the use of glasses or
contact lenses, the following statement shall appear on the
Medical Examiner's Certificate: "Qualified only if wearing
corrective lenses."
CMV drivers who do not meet the Federal vision standard
may call (202) 366-1790 for an application for a vision
exemption.
(See Visual Disorders and Commercial Drivers at:
//www.fmcsa.dot.gov/rulesregs/medreports.htm)
Hearing
§391.41(b)(11)
A person is physically qualified to drive a commercial motor
vehicle if that person:
First perceives a forced whispered voice in the better ear at not
less than 5 feet with or without the use of a hearing aid, or, if
tested by use of an audiometric device, does not have an
average hearing loss in the better ear greater than 40 decibels
at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid
when the audiometric device is calibrated to American National
Standard (formerly ADA Standard) Z24.5-1951.
Since the prescribed standard under the FMCSRs is the
American Standards Association (ANSI), it may be necessary to
convert the audiometric results from the ISO standard to the
ANSI standard. Instructions are included on the Medical
Examination report form.
If an individual meets the criteria by using a hearing aid, the
driver must wear that hearing aid and have it in operation at all
times while driving. Also, the driver must be in possession of a
spare power source for the hearing aid.
For the whispered voice test, the individual should be
stationed at least 5 feet from the examiner with the ear being
tested turned toward the examiner. The other ear is covered.
Using the breath which remains after a normal expiration, the
examiner whispers words or random numbers such as 66, 18,
23, etc. The examiner should not use only
sibilants (s sounding materials). The opposite
ear should be tested in the same manner. If the
individual fails the whispered voice test, the
audiometric test should be administered.
If an individual meets the criteria by the use
of a hearing aid, the following statement must
appear on the Medical Examiner's Certificate
"Qualified only when wearing a hearing aid."
(See Hearing Disorders and Commercial Motor
Vehicle Drivers at:
//www/fmcsa.dot.gov/rulesregs/medreports.
htm)
Drug Use
§391.41(b)(12)
A person is physically qualified to drive a
commercial motor vehicle if that person does
not use any drug or substance identified in 21
CFR 1308.11, an amphetamine, a narcotic, or
other habit-forming drug. A driver may use a
non-Schedule I drug or substance that is
identified in the other Schedules in 21 part 1308
if the substance or drug is prescribed by a
licensed medical practitioner who: (A) is familiar
with the driver’s medical history, and assigned
duties; and (B) has advised the driver that the
prescribed substance or drug will not adversely
affect the driver’s ability to safelyoperate a
commercial motor vehicle.
This exception does not apply to methadone.
The intent of the medical certification process is
to medicallyevaluate a driver to ensure that the
driver has no medical condition which interferes
with the safe performance of driving tasks on a
public road. If a driver uses an amphetamine, a
narcotic or any other habit-forming drug, it may
be cause for the driver to be found medically
unqualified. If a driver uses a Schedule I drug or
substance, it will be cause for the driver to be
found medically unqualified. Motor carriers are
encouraged to obtain a practitioner's written
statement about the effects on transportation
safetyof the use of a particular drug.
A test for controlled substances is not
required as part of this biennial certification
process. The FMCSA or the driver's employer
should be contacted directly for information on
controlled substances and alcohol testing under
Part 382 of the FMCSRs.
The term "uses" is designed to encompass
instances of prohibited drug use determined by
a physician through established medical means.
This may or may not involve body fluid testing.
If body fluid testing takes place, positive test
results should be confirmed by a second test of
greater specificity. The term "habit-forming" is
intended to include any drug or medication
generally recognized as capable of becoming
habitual, and which may impair the user's ability
to operate a commercial motor vehicle safely.
The driver is medically unqualified for the
duration of the prohibited drug(s) use and until a
second examination shows the driver is free
from the prohibited drug(s) use. Recertification
may involve a substance abuse evaluation, the
successful completion of a drug rehabilitation
program, and a negative drug test result.
Additionally, given that the certification period is
normally two years, the examiner has the option
to certify for a period of less than 2 years if this
examiner determines more frequent monitoring
is required.
(See Conference on Neurological Disorders and
Commercial Drivers and Conference on
Psychiatric Disorders and Commercial Drivers
at:
//www.fmcsa.dot.gov/rulesregs/medreports.
htm)
Alcoholism
§391.41(b)(13)
A person is physically qualified to drive a
commercial motor vehicle if that person:
Has no current clinical diagnosis of alcoholism.
The term "current clinical diagnosis of" is
specifically designed to encompass a current
alcoholic illness or those instances where the
individual's physical condition has not fully
stabilized, regardless of the time element. If an
individual shows signs of having an alcohol-use
problem, he or she should be referred to a
specialist. After counseling and/or treatment, he
or she maybe considered for certification.
MEDICAL EXAMINER’S CERTIFICATE
I certify that I have examined in accordance with the Federal Motor Carrier
Safety Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when:
wearing corrective lenses
driving within an exempt intracity zone (49 CFR 391.62)
wearing hearing aid
accompanied by a Skill Performance Evaluation Certificate (SPE)
accompanied by a waiver/exemption
qualified by operation of 49 CFR 391.64
The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies
my findings completely and correctly, and is on file in my office.
SIGNATURE OF MEDICAL EXAMINERTELEPHONEDATE
MEDICAL EXAMINER’S NAME (PRINT)
MD
Chiropractor
DO
Advanced Practice Nurse
Physician Assistant
Other Practitioner
MEDICAL EXAMINER’S LICENSE
OR CERTIFICATE NO./ISSUING
STATE
NATIONAL REGISTRY NO.
SIGNATURE OF DRIVERINTRASTATE ONLY
YES
NO
CDL
YES
NO
DRIVER’S LICENSE NO.STATE
ADDRESS OF DRIVER
MEDICAL CERTIFICATION EXPIRATION DATE
