Medical Examination Report Form - Driver Information - Rev 3/29/2022

Sep 18, 2026

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Medical Examination Report Form for commercial driver medical certification. The form collects driver personal information, identity verification details, and medical certificate history status, then gathers health history including surgeries, current medications, and a comprehensive list of medical conditions such as neurological, cardiovascular, respiratory, renal, digestive, diabetes, mental health, sleep disorders, and substance use. It includes instructions to attach additional sheets, a sensitive-information handling notice, and a driver certification signature section. It also provides an examiner section for health history review and discussion of driver answers and supporting medical records.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Section 1. Driver Information (to be filled out by the driver)

Personal information

Driver health history

Driver’s signature

Section 2. Examination Report (to be filled out by the medical examiner)

Driver health history review

| | Public Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 25 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All | | | --- | --- | --- | |
| responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590. | | | U.S. Department of Transportation
Federal Motor Carrier
Safety Administration | | Medical Examination Report Form
(for Commercial Driver Medical Certification) | SECTION 1. Driver Information (to be filled out by the driver) PERSONAL INFORMATION MEDICAL RECORD \# (or sticker) Last Name: First Name: Middle Initial: Date of Birth: Age: Street Address: City: State/Province: Zip Code: Driver’s License Number: Issuing State/Province: Phone: E-Mail (optional): CLP/CDL Applicant/Holder*: Yes No Driver ID Verified By**: Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years? Yes No Not Sure *CLP/CDL Applicant/Holder: See instructions for definitions. **Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver’s license, passport. DRIVER HEALTH HISTORY | Have you ever had surgery? If “yes,” please list and explain below. Yes No Not Sure | | | --- | --- | | Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If “yes,” please describe below. | Yes No Not Sure | (Attach additional sheets if necessary) **This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.** Rev 3/29/2022 Page 1 Last Name: First Name: DOB: Exam Date: DRIVER HEALTH HISTORY (continued) | Not Not
Do you have or have you ever had: Yes No Sure Yes No Sure | | | --- | --- | | 1. Head/brain injuries or illnesses (e.g., concussion)
2. Seizures/epilepsy
3. Eye problems (except glasses or contacts)
4. Ear and/or hearing problems
5. Heart disease, heart attack, bypass, or other heart problems
6. Pacemaker, stents, implantable devices, or other heart procedures
7. High blood pressure
8. High cholesterol
9. Chronic (long-term) cough, shortness of breath, or other breathing problems
10. Lung disease (e.g., asthma)
11. Kidney problems, kidney stones, or pain/problems with urination
12. Stomach, liver, or digestive problems
13. Diabetes or blood sugar problems Insulin used
14. Anxiety, depression, nervousness, other mental health problems
15. Fainting or passing out | 16. Dizziness, headaches, numbness, tingling, or memory loss
17. Unexplained weight loss
18. Stroke, mini-stroke (TIA), paralysis, or weakness
19. Missing or limited use of arm, hand, finger, leg, foot, toe
20. Neck or back problems
21. Bone, muscle, joint, or nerve problems
22. Blood clots or bleeding problems
23. Cancer
24. Chronic (lo

FAQs

What information does Section 1 collect from the driver?

Section 1 collects personal details, identity verification type, medical certificate denial/issuance history, and answers to health history questions including surgeries, current medications, and conditions 1–32. It also allows additional notes and attached sheets.

How does the driver certify the accuracy of the medical information?

The driver signs under “CMV Driver’s Signature,” certifying the information is accurate and complete. The form warns that inaccurate, false, or missing information may invalidate the examination and certificate and may lead to penalties.

What does the medical examiner complete in Section 2?

Section 2 requires the medical examiner to review and discuss relevant driver answers and any available medical records. It includes comments about health history responses that may affect safe operation of a commercial motor vehicle.

Sep 18, 2026

Upload by Paura