Medical Examination Report for Commercial Driver Fitness Determination - University of Virginia

Medical Examination Report

FOR COMMERCIAL DRIVER FITNESS DETERMINATION

649-F (6045)

DRIVER'S INFORMATION

Driver completes this section

Date of Exam

Recertification

M / D / Y

Driver's Name (Last, First, Middle)

Social Security No.

Birthdate

Age

Sex

New Certification

Follow-up

ddress City, State, Zip Code Work Tel: ( )

Driver License No.

License Class State of Issue

Home Tel: ( )

Other

HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver.

Yes No

Lung disease, emphysema, asthma, chronic bronchitis

Fainting, dizziness

Any illness or injury in the last 5 years?

Kidney disease, dialysis

Sleep disorders, pauses in breathing

Head/Brain injuries, disorders or illnesses

Liver disease

while asleep, daytime sleepiness, loud

Seizures, epilepsy

snoring

Digestive problems

medication_______________________________

Diabetes or elevated blood sugar controlled by:

Stroke or paralysis

Eye disorders or impaired vision (except corrective lenses)

diet

Missing or impaired hand, arm, foot, leg,

Ear disorders, loss of hearing or balance

pills

finger, toe

Heart disease or heart attack; other cardiovascular condition

insulin

Spinal injury or disease

medication_______________________________

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

medication____________________

Chronic low back pain

Heart surgery (valve replacement/bypass, angioplasty,

pacemaker)

Regular, frequent alcohol use

Loss of, or altered consciousness

High blood pressure medication___________________

Narcotic or habit forming drug use

Muscular disease

Shortness of breath

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.

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. )

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