NaoMedical - Provider CDL Medical Examination Form

PHYSICAL EXAMINATION

The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen, or is readily amenable to treatment. Even if a condition does not disqualify a driver, the Medical Examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible, particularly if neglecting the condition could result in a more serious illness that might affect driving.

Check the body systems for abnormalities.

Body System

Normal

Abnormal

Body System

Normal

Abnormal

1. General

8. Abdomen

2. Skin

9. Genito-urinary system including hernias

3. Eyes

10. Back/spine

4. Ears

11. Extremities/joints

5. Mouth/throat

12. Neurological system including reflexes

6. Cardiovascular

13. Gait

7. Lungs/chest

14. Vascular system

Discuss any abnormal answers in detail in the space below and indicate whether it would affect the driver's ability to operate a CMV. Enter applicable item number before each comment.

(Attach additional sheets if necessary)

MEDICAL EXAMINER DETERMINATION (Federal)

Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49):

If the driver meets the standards outlined in 49 CFR 391.41, then complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h), as appropriate.

I have performed this evaluation for certification. I have personally reviewed all available records and recorded information pertaining to this evaluation, and attest that, to the best of my knowledge, I believe it to be true and correct.

Medical Examiner's Signature:

Please sign above using your mouse or finger on touch devices

Medical Examiner's Name (please print or type):

Medical Examiner's Address:

City:

State:

Zip Code:

Medical Examiner's Telephone Number:

Date Certificate Signed:

Medical Examiner's State License, Certificate, or Registration Number:

Issuing State:

Medical Examiner's Qualification:

MD

DO

Physician Assistant

Chiropractor

Advanced Practice Nurse

Other Practitioner (specify):

National Registry Number:

Medical Examiner's Certificate Expiration Date:

MEDICAL EXAMINER DETERMINATION (State)

Use this section for examinations performed in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) with any applicable State variances (which will only be valid for intrastate operations):

If the driver meets the standards outlined in 49 CFR 391.41, with applicable State variances, then complete a Medical Examiner's Certificate, as appropriate.