Form 649-F - Medical Examination Report For Commercial Driver Fitness Determination printable pdf download

Form 649-F - Medical Examination Report For Commercial Driver Fitness Determination

Medical Examination Report

FOR COMMERCIAL DRIVER FITNESS DETERMINATION

649-F (6045)

DRIVER'S INFORMATION

Driver completes this section

Driver's Name (Last, First, Middle)

Social Security No.

Birthdate

Age

Sex

New Certification

Date of Exam

Recertification

M / D / Y

Follow-up

Address

City, State, Zip Code

Work Tel: ( )

Driver License No.

License Class

State of Issue

Home Tel: ( )

Other

HEALTH HISTORY

Driver completes this section, but medical examiner is encouraged to discuss with driver.

Yes No

Lung disease, emphysema, asthma, chronic bronchitis

Fainting, dizziness

Any illness or injury in the last 5 years?

Kidney disease, dialysis

Sleep disorders, pauses in breathing

Head/Brain injuries, disorders or illnesses

Liver disease

while asleep, daytime sleepiness, loud

Seizures, epilepsy

snoring

Digestive problems

medication_______________________________

Diabetes or elevated blood sugar controlled by:

Stroke or paralysis

diet

Eye disorders or impaired vision (except corrective lenses)

Missing or impaired hand, arm, foot, leg,

pills

Ear disorders, loss of hearing or balance

finger, toe

insulin

Heart disease or heart attack; other cardiovascular condition

Spinal injury or disease

medication_______________________________

Nervous or psychiatric disorders, e.g., severe depression

medication____________________

Chronic low back pain

Heart surgery (valve replacement/bypass, angioplasty,

pacemaker)

Regular, frequent alcohol use

Loss of, or altered consciousness

High blood pressure

medication___________________

Narcotic or habit forming drug use

Muscular disease

Shortness of breath

For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including

over-the-counter medications) used regularly or recently.

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my

Medical Examiner's Certificate.

Driver's Signature

Date

Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of

medications, including over-the-counter medications, while driving. This discussion must be documented below. )