Live Well Medical Care P.C. : DOT Physical

DOT Physical Form

A DOT physical form, also known as a Department of Transportation physical form, is a standardized document used to assess the physical fitness of commercial motor vehicle drivers to ensure they meet the health and safety requirements necessary for operating commercial vehicles on public roads. This form is typically completed by a certified medical examiner and includes details about the driver's health, medical history, and physical examination results.

Preferred Location *

SECTION 1. Driver Information (to be filled out by the driver)

PERSONAL INFORMATION

Last Name^*

First Name^*

Middle Name

Date of Birth^*

Age

Street Address

City

State/Province

Zip Code

Driver’s License Numbe

Issuing State/Province

Phone

E-Mail (optional)

CLP/CDL Applicant/Holder *

Male

Female

Driver ID Verified By **:

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?

Yes

Not Sure

*CLP/CDL Applicant/Holder: See instructions for definitions
**Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver’s license, passport

DRIVER HEALTH HISTORY

Have you ever had surgery?

Yes

Not Sure

If “yes,” please list and explain below

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?

Yes

Not Sure

If “yes,” please describe below.

Attach additional sheets if necessary

**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.**

Last Name: First Name: DOB: Exam Date:

DRIVER HEALTH HISTORY (continued)

Do you have 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
14. Diabetes or blood sugar problems Insulin used
15. Fainting or passing out
16. Anxiety, depression, nervousness, other mental health problems

	Yes	No	Not Sure
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?

Other health condition(s) not described above

Yes

Not Sure

Did you answer “yes” to any of questions 1-32?

Yes

Not Sure

If so, please comment further on those health conditions below:

Attach additional sheets if necessary

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DOT Physical Form

Medical Examination Report Form

(for Commercial Driver Medical Certification)

MEDICAL RECORD #

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