NaoMedical - MA CDL Medical Examination Form

Patient Name: Loading... | DOB: Loading...

Examination Date:

DRIVER HEALTH HISTORY REVIEW

Review and discuss pertinent driver answers and any available medical records. Comment on the driver's responses to the "health history" questions that may affect the driver's safe operation of a commercial motor vehicle (CMV).

(Attach additional sheets if necessary)

TESTING

Pulse Rate:

Pulse rhythm regular:

Yes

Height:

feet inches

Weight:

pounds

Blood Pressure

	Systolic	Diastolic
Sitting
Second reading (optional)

Urinalysis

Urinalysis is required. Numerical readings must be recorded.

Sp. Gr.	Protein	Blood	Sugar

Protein, blood, or sugar in the urine may be an indication for further testing to rule out any underlying medical problem.

Other testing if indicated:

Vision

Standard is at least 20/40 acuity (Snellen) in each eye with or without correction. At least 70° field of vision in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.

Acuity

Uncorrected

Corrected

Horizontal Field of Vision

Right Eye:

20/

degrees

Left Eye:

20/

degrees

Both Eyes:

20/

Applicant can recognize and distinguish among traffic control signals and devices showing red, green, and amber colors:

Yes

Monocular vision:

Yes

Referred to ophthalmologist or optometrist?

Yes

Received documentation from ophthalmologist or optometrist?

Yes

Hearing

Standard: Must first perceive whispered voice at not less than 5 feet OR average hearing loss of less than or equal to 40 dB, in better ear (with or without hearing aid).

Check if hearing aid used for test:

Right Ear

Left Ear

Neither

Whisper Test Results:

Record distance (in feet) from driver at which a forced whispered voice can first be heard

Right Ear:

feet

Left Ear:

feet

Audiometric Test Results:

Right Ear:

500 Hz

1000 Hz

2000 Hz

Average:

Left Ear:

500 Hz

1000 Hz

2000 Hz

Average:

Medical Assistant CDL Examination Form