How to Fill out the Form
New Form Driver Instructions:
- Driver to use name on current license. Driver is to use their current address at which they live.
- Driver determines if they are a CDL/CLP (driver permit) holder or applicant according to CMV description
- Medical examiner fills out the source of ID such as CDL license, drivers’ license or passport, etc.
- Driver indicates if their medical certification has ever been denied or was issued for less than 2 years. You may answer YES, NO, or NOT SURE. Answer YES if you have ever had a medical certification card issued to you for anything less than 2 years (such as 1 year because you are treated or have a history of high blood pressure).
You may download the form and/or fill out the driver section of the form for free below. For those Pass My Physical PLUS members, you may download your completed form from you account (coming soon).
Filling out the Driver Health History section:
- Have you ever had surgery: Please check YES if you have ever had surgery in your lifetime, and provide a written explanation of the details (type of surgery, date of surgery, doctor who performed surgery, and results such as successful, still have problems, etc.
- Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements such as vitamins): Please check YES if you are taking any of the above in the appropriate box, then in the area below the question, indicate the name of the medication and the dosage.
- History Questions 1 through 32: Mark YES, NO, or NOT SURE in the box next to each question in this section. For any YES answer, explain your answer in the area provided, list the problem that occurred, the date, the doctor who treated it, and the outcome. For example, if you marked YES to question # 5 regarding heart disease, heart attack, bypass, or other heart problem, indicate the type of heart condition, followed by the rest of the information described above.
- Other Health Conditions not described above: If you have, or have had, any other health conditions not listed in questions 1 through 32 above, check YES in the appropriate box. An example may be a skin condition you are or have been treated for, such as psoriasis. Explain your answer in the area provided by listing the problem or condition, the date if appropriate, the doctor who treated it, and the outcome.
Signatures:
There is one place on the form that requires a drivers signature. It is at the end of section 1, near the bottom of page 2 on the form.
By signing here, the driver indicates that the information provided is true and accurate, and stipulates the criminal penalties for falsifying or providing incomplete or inaccurate information.
Much of the information listed in this program has been taken directly from FMCSA guidance and regulations as well as from the national conference reports on their respective medical conditions.
Medical Examiners may differ slightly on how the guidelines are interpreted and what may be required for the driver to bring with them on exam day. By using the information provided and tools such as clearance letters for treating providers, the driver will have a significantly improved chance of getting certified following their DOT Medical Exam. There are no guarantee of medical certification.