DOT Physical Form
Form MCSA-5875
PERSONAL INFORMATION
Name
*
First Name
Middle Initial
Last Name
Date of Birth
*
/
Month
/
Day
Year
Date
Age
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
State/Province
*
Please Select
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Zip Code
*
Driver's License Number
*
Issuing State/Province
*
Please Select
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
AB
BC
MB
NB
NL
NS
NT
NU
ON
PE
QC
SK
YT
Phone
*
Exam Date
/
Month
/
Day
Year
Date
Gender:
*
M
F
E-mail (optional)
example@example.com
CLP/CDL Applicant/Holder:
*
Yes
No
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?
*
Yes
No
Not Sure
DRIVER HEALTH HISTORY
Have you ever had surgery? If "yes," please list and explain below.
*
Yes
No
Not Sure
Explain
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If "yes," please describe below.
*
Yes
No
Not Sure
If "yes," please describe below.
Do you or have you ever had:
*
Yes
No
Not Sure
1. Head/brain injuries or illnesses (e.g., concussion)
2. Seizures, epilepsy
3. Eye problems (except glasses or contacts)
4. Ear and/or hearing problems
5. Heart disease, heart attack, bypass, or other heart problems
6. Pacemaker, stents, implantable devices, or other heart procedures
7. High blood pressure
8. High cholesterol
9. Chronic (long-term) cough, shortness of breath, or other breathing problems
10. Lung disease (e.g., asthma)
11. Kidney problems, kidney stones, or pain/problems with urination
12. Stomach, liver, or digestive problems
13. Diabetes or blood sugar problems
Insulin used
Insulin used
14. Anxiety, depression, nervousness, other mental health problems
15. Fainting or passing out
16. Dizziness, headaches, numbness, tingling, or memory loss
17. Unexplained weight loss
18. Stroke, mini-stroke (TIA), paralysis, or weakness
19. Missing or limited use of arm, hand, finger, leg, foot, toe
20. Neck or back problems
21. Bone, muscle, joint, or nerve problems
22. Blood clots or bleeding problems
23. Cancer
24. Chronic (long-term) infection or other chronic diseases
25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
26. Have you ever had a sleep test (e.g., sleep apnea)?
27. Have you ever spent a night in the hospital?
28. Have you ever had a broken bone?
29. Have you ever used or do you now use tobacco?
30. Do you currently drink alcohol?
31. Have you used an illegal substance within the past two years?
32. Have you ever failed a drug test or been dependent on an illegal substance?
Did you answer "yes" to any of questions 1-32?
*
Yes
No
No
If so, please comment further on those health conditions below:
Do you have any other health condition(s) not described above
*
Yes
No
Not Sure
Please explain:
CMV DRIVER'S SIGNATURE
Driver's Signature
*
Date Signed
/
Month
/
Day
Year
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