PASS MY PHYSICAL Q&A
WHAT DO I NEED BEFORE MY EXAM TO LIMIT THE POSSIBILITY OF ANY DELAYS?
You want to arrive prepared for the medical examination to prevent delays in certification. In addition to knowing any medications you are taking and all surgeries you have ever had, you will also be required to answer the 32 history questions on the form. Your answers will be YES, NO, or NOT SURE. For any YES answer, you will need to provide added information in the space provided on the form.
You should provide:
- The number of the question (1, 2, 17 etc.)
- What the condition is (for example “Heart Attack”)
- The year it happened.
- Who treated and where they are (Dr. Jones, Syracuse, NY)
- The outcome (well managed, successful, still treating etc.)
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Review the following questions, 1 through 32 to determine what you will need before you go. Use the key provided. For those yes answers, if you need medical clearance, Required testing or you need to find out if there are waiting periods, “click” here to purchase a medical clearance letter attached to your condition or treatment. The medical clearance letters provide all you need. Just take them to your treating provider, they review it and if you meet all the requirements all they need do is sign the form. It’s as simple as that!
Not sure what you need? Print out the generic clearance form and take it to your treating provider. We have something for all conditions and treatments.
KEY for abbreviations below:
RMC – Required Medical Clearance
MC – Medical Clearance may be needed
RMT – Required Medical Testing will be needed
WP – A waiting period may be required prior to certification
COMPLETE YOUR FORM USING OUR SECURE MOBILE APP
Once you understand what is required of you in the questions below, complete your form by using our PASS MY PHYSICAL MOBILE APP. Information you provide will be confidential to you, and stored by our app in a secure manner meeting HIPAA compliance criteria. Conveniently, the app will issue you ALERT NOTICES so you will know of a possible waiting period (WP), or if a condition will require medical clearance (RMC), or when it is possible that required medical testing (RMT) will be needed.
The online form will ask you the following questions (per 49 CFR Part 391.43):
- Have you had any head or brain injuries or illnesses? This would include concussions, more severe head injuries, and brain and spinal cord infections such as meningitis, or encephalitis. If so, mark yes on the form and list below the injury or illness and the outcome. WP, RMC
- Have you ever had a seizure, regardless of how it happened? How many have you had? Have you ever been diagnosed with epilepsy? Have you ever been prescribed medication to treat or prevent seizures? If so, mark yes on the form and list below your diagnosis, when the seizure occurred and what was done to treat it. WP, RMC
- Do you have any eye problems other than wearing glasses? This would include such things as eye infections, glaucoma, macular degeneration, cataracts, etc. If you have had an eye problem, mark yes on the form, and put the information in the box provided, and include your diagnosis and what kind of treatment you have. RMC possible
- Do you have any ear or hearing problems? This would include hearing loss, infections in the ear, a history of balance issues associated with the inner ear, have you required ear surgery etc. If so, mark yes, and explain in the space provided. RMC possible
- Have you ever been diagnosed with heart disease (angina, heart attack, irregular heart-beat, heart valveproblem)? If so, mark yes on the form, and put the information in the box provided. WP, RMC, RMT
- Have you had a pacemaker, stents, other implantable devices or other heart procedures or surgeries (by-pass surgery, valve repair or replacement surgery, heart transplant)? If so, mark yes and put in your information is the space provided. WP, RMC, RMT
- Have you ever been diagnosed with high blood pressure, taken medication for high blood pressure, whether it is in a DOT medical exam, or with your private physician? If so, mark yes and list the information in the space provided.
- Have you ever been diagnosed and/or treated for high cholesterol? If so, mark yes in the form and list the information below.
- Do you have a chronic cough (cough frequently every day), have shortness of breath, or have any other breathing problems? If so, mark yes on the form, and put the information in the box provided. MC, RMT
- Do you have any lung problems or diseases? This would include such things as asthma, emphysema, COPD, tuberculosis, collapsed lung, or any other lung disease or infection? If you do or have suffered from these, mark yes on the form and put the information concerning your problem in the box provided. RMC, RMT
- Do you suffer from any kidney problems, such as kidney stones, pain with urination, etc.? Are you currently or have you ever been on dialysis? If so, mark yes on the form and put the information in the box provided. MC possible
- Do you have any stomach problems such as ulcers, digestive problems (such as acid reflux), liver problems (such as cirrhosis)? If so mark yes on the form and put the information concerning these problems in the box provided. RMC not likely but possible for certain conditions.
- Do you suffer from diabetes or other blood sugar problems? If so, mark yes on the form, and in the box provided write in how long you were treated in the box provided. RMT
A related question regarding insulin use is also provided. If you use any form of insulin, mark yes on the form and provide that information in the box provided. - Are you treated for depression, anxiety, nervousness, PTSD, anger management, bi-polar disorder, psychosis, ADHD, schizophrenia or any other mental condition? If so mark yes on the form, and put the information about your condition in the box provided. RMC
- Have you ever suffered a fainting spell or passed out for any reason ever in your lifetime? If so, mark yes on the form, and put the information relating to the episode in the box provided. RMC
- Have you ever, or do you now suffer from dizziness, headaches such as migraines, numbness, tingling, or memory loss. If so, mark yes on the form and put the information in the box provided. MC
- Have you currently noticed any unexplained weight loss? If so, mark yes on the form and explain in the box provided. MC
- Have you ever suffered an embolic or thrombotic or an intracerebral or subarachnoid stroke, mini stroke (TIA), had any paralysis or weakness in a body part? If so, mark yes, and explain in the box provided. WP, RMC
- Are you missing any part of a hand, foot, arm or leg, or have a limitation in a hand, foot, arm or leg (inability to move in all directions, lack of strength etc.). If so, mark yes on the form and explain in the box provided. MC
- Do you now, or have you ever suffered back or neck problems. If so mark yes on the form and explain when and what your problem was in the box provided. MC
- Have you suffered any bone, muscle, joint problems or nerve problems? This may include things such as arm or leg injuries, carpal tunnel syndrome, muscular dystrophy, Lou Gehrig’s disease etc. MC
- Have you ever had a blood clot in your leg or anywhere else, or do you have any blood conditions? Examples include, DVT, pulmonary embolism, any form of anemia, or other blood condition such as clotting problems like hemophilia. If so mark yes on the form and explain in the box provided. MC, RMT for some conditions.
- Have you ever suffered from any form of cancer? If so, mark yes on the form, and explain the type of cancer, and results of treatment in the box provided. MC
- Do you suffer any chronic long term infection, or have any other chronic diseases. Examples may include hepatitis, AIDS, and others. If so, mark yes on the form, and explain in the box provided. MC
- Do you have, or have you ever been diagnosed with a sleep disorder such as sleep apnea, or narcolepsy? Do you snore loudly, have any pauses in breathing during sleep or suffer from daytime sleepiness? If so, mark yes on the form and explain in the box provided. MC, RMT
- Have you ever had a sleep test (like for sleep apnea)? If so mark yes on the form and put in the date and the results in the box provided. MC
- Have you ever spent a night in the hospital? If so mark yes on the form and explain in the box provided (when and why). MC
- Have you ever had a broken bone? If so, mark yes on the form, and describe in the box provided (when, result such as fully healed, or had surgery to repair etc.). MC
- Have you ever used, or do you currently use tobacco? This includes smoking of any kind, and if you chew tobacco. If you do mark yes on the form, and list how much and often in the box provided.
- Do you currently drink alcohol? If so, mark yes on the form and list how much and how often in the box provided. MC based on amount used, or previous positive random alcohol test.
- Have you used an illegal substance in the past 2 years? If so mark yes on the form, and explain in the box provided. RMC
- Have you ever failed a drug test or been dependent on an illegal substance? If so, mark yes on the form and explain in the box provided. RMC
Not sure which MEDICAL CLEARANCE LETTERS you need? Download the FREE PASS MY PHYSICAL MOBILE APP and let the app figure this out for you.
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