DOT Physical Examination Form
Driver Information
Full Name
Date of Birth
Driver's License Number
State
Address
Phone Number
Medical History
Health conditions, medications, or allergies
Vital Signs
Height
Weight
Blood Pressure
Pulse
Vision (Left/Right)
Hearing (Left/Right)
Physical Examination
General Appearance
Eyes
Ears
Mouth/Throat
Heart
Lungs
Abdomen
Extremities
Neurological
Other Comments
Certification
The driver named above is medically qualified to operate a commercial motor vehicle in accordance with DOT regulations:
Qualified
Temporarily Disqualified
Permanently Disqualified
Comments and Restrictions
Medical Examiner Name
Date
Medical Examiner Signature
License/Certificate Number