Driving Instructor Physical Form
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COMMERCIAL DRIVER TRAINING SECTION
Office of the Secretar y of State
650 ROPPOLO DR.
ELK GROVE VILLAGE, IL 60007
Driver Ser vices Depar tment
312-793-1010
Driving Instructor Physical Form
Instructor/Applicant Name:
Describe any history of Epilepsy, Heart Disease or Fainting Spells:
Heart
Blood Pressure
Pulse Rate
Respiratory System
Reflexes
Genito Urinary System
Urine
Does Applicant have the normal use of both (answer “yes” or “no”; describe under remarks)
Arms ______ Hands ______ Legs ______ Feet ______ Eyes ______
Mental Alertness (observation)
Hearing
Hearing Results
Deaf ______ Poor ______ Fair ______ Good ______
Both ______ Right ______ Left ______
Acuity Reading with Glasses
Acuity Reading without Glasses
Both 20/
Right 20/
Left 20/
Both 20/
Right 20/
Left 20/
Remarks:
Physician please note: Applicant must sign in the
presence of the examining physician.
Applicant’s Signature
I certify that I have correctly recorded the results of the examination, and that to the best of my judgement the applicant
is ____ is not ____ physically qualified to train an individual in the operation of a motor vehicle. (State any exceptions)
M.D.
Place of Examination
Physician’s Signature
Physician’s Address
Date of Examination
Month
Day
Year
When you have completed this form, mail to the Office of the Secretary of State, Commercial Driver Training School
Section, 650 Roppolo Lane, Elk Grove Village, IL 60007.
Printed by authority of the State of Illinois - May 2013 - 1 - DSD CDTS 57.3
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