NaoMedical - CDL Medical Form

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

PERSONAL INFORMATION

Last Name:

First Name:

Middle Initial:

Date of Birth:

Age:

Street Address:

City:

State/Province:

Zip Code:

Driver's License Number:

Issuing State/Province:

Phone:

E-Mail (optional):

CLP/CDL Applicant/Holder*:

Yes

*CLP/CDL Applicant/Holder: See instructions for definitions.

Driver ID Verified By**:

**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.

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

Yes

Not Sure

DRIVER HEALTH HISTORY

Have you ever had surgery? If "yes," please list and explain below.

Yes

Not Sure

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If "yes," please describe below.

Yes

Not Sure

Do you have or have you ever had:
	Yes	No	Not Sure		Yes	No	Not Sure
1. Head/brain injuries or illnesses (e.g., concussion)				16. Dizziness, headaches, numbness, tingling, or memory loss
2. Seizures/epilepsy				17. Unexplained weight loss
3. Eye problems (except glasses or contacts)				18. Stroke, mini-stroke (TIA), paralysis, or weakness
4. Ear and/or hearing problems				19. Missing or limited use of arm, hand, finger, leg, foot, toe
5. Heart disease, heart attack, bypass, or other heart problems				20. Neck or back problems
6. Pacemaker, stents, implantable devices, or other heart procedures				21. Bone, muscle, joint, or nerve problems
7. High blood pressure				22. Blood clots or bleeding problems
8. High cholesterol				23. Cancer
9. Chronic (long-term) cough, shortness of breath, or other breathing problems				24. Chronic (long-term) infection or other chronic diseases
10. Lung disease (e.g., asthma)				25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
11. Kidney problems, kidney stones, or pain/problems with urination				26. Have you ever had a sleep test (e.g., sleep apnea)?
12. Stomach, liver, or digestive problems				27. Have you ever spent a night in the hospital?
13. Diabetes or blood sugar problems				28. Have you ever had a broken bone?
Insulin used				29. Have you ever used or do you now use tobacco?
14. Anxiety, depression, nervousness, other mental health problems				30. Do you currently drink alcohol?
15. Fainting or passing out				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? If so, please comment further on those health conditions below:

Yes

Not Sure

CMV DRIVER'S SIGNATURE

I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.

Driver's Signature:

Please sign above using your mouse or finger on touch devices

Date:

Commercial Driver Medical Examination Form

Form Already Submitted