21081 S. Western Ave. Suite 150, Torrance, CA 90501

Western Medical Group

DMV

  • Medical Examination Report for Commercial Driver Fitness Determination

  • 1. DRIVER INFORMATION. Driver completes this section. PRINT IN CAPITAL LETTERS - USING BLACK OR DARK BLUE INK.
  • PLEASE READ THE "INSTRUCTIONS TO THE DRIVER"BEFORE ANSWERING.
  • PLEASE READ THE FOLLOWING INFORMATION

    If you indicated you have submitted this medical examination report for one or more of the certificates listed above, your medical examination MUST be performed by a Physician Assistant, Advanced Practice Registered Nurse, Doctor of Medicine (MD), or Doctor of Osteopathy (D0).Your medical examination report and medical certificate MUST be signed by the physician who performed the examination. If your medical examination report does not indicate your medical examination was performed and signed by an MD, DO, Physician Assistant, or Advanced Practice Registered Nurse, DMV will not process your certificate application or accept your medical examination report, and your medical examination report will be returned to you.
  • 2. HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driller.
  • I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I understand that inaccurate false or missing information may invalidate the examination and my. Medical Examiner's Certification.
  • MEDICAL EXAMINER COMPLETES SECTIONS 3 THROUGH 8


    Check each item in appropriate box to show"Qualified" or "Not Qualified': Explain any special findings or test results NOT in an acceptable tolerance range.
  • Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate. INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator if the applicant wears corrective lenses, these should be worn while acuity is being tested. It the driver habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.
  • Numerical readings must be provided.
  • Horizontal field of vision
  • Complete next line only if vision testing is done by an ophthalmologist or optometrist
  • INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, - 14 dB from ISO for 500 Hz, - 10dB for 1,000 Hz, - 8.5 dB for 2,000 Hz. To average, add the readings for 3 frequencies tested and divide by 3.
  • Numerical readings must be recorded.
  • a) Record distance from individual at which forced whispered voice can first be heard.
  • b) If audiometer is used, record hearing loss in decibels. (Acct. to ANSIZ24.5-1951)
  • Right Ear
  • Left Ear
  • Blood Pressure
  • Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.
    READING HYPERTENSION CATEGORY EXPIRATION DATE FOR CERTIFICATE RECERTIFICATION
    139/89 or lower with no history of Stage 1-3 hypertension currently requiring medication N/A
    Driver qualified
    2 years Every 2 years
    140-159/90-99 Stage 1 1 year 1 year if 140/90 or less. One-time certificate for 3 months if 141-159/91-99.
    160-179/100-109 Stage 2 One-time certificate for 3 months 1 year from date of exam if 140/90 or less
    180/110 or higher Stage 3 N/A
    Driver qualified
    6 months from date of exam if 140/90 or less
  • Urinalysis is required. Protein, blood or sugar in the urine may be an Indication for further testing to rule out any underlying medical problem.
    Numerical readings must be recorded.
    URINE SPECIMEN
  • 7. Physical Examination
  • The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible, particularly if the condition, if neglected, could result in more serious illness that might affect driving.
    Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for. Check each item in appropriate box to show "Qualified" or "Not Qualified?
    As you complete items 1 - 12 below, you will find some items that have no clearly defined measures to indicate a driver is "qualified" or "not qualified? For such items, please check "qualified" if the driver's condition appears within normal limits.
    See Instructions To The Medical Examiner for guidance.
  • Check for: Marked overweight, tremor, signs of alcoholism, problem drinking, or drug abuse.
  • Check for: Papillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extra-ocular movement, nystagmus, exophthalmos, strabismus uncorrected by corrective lenses, retinopathy, cataracts, aphakia, glaucoma, muscular degeneration.
  • Check for: Middle ear disease, occlusion of external canal, perforated eardrums.
  • Check for: Irremediable deformities likely to interfere with breathing or swallowing.
  • Check for: Murmurs, extra sounds, enlarged heart, pacemaker.
  • Check for: Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales, impaired respiratory function, dyspnea, cyanosis. Abnormal findings on physical exam may require further testing such as pulmonary tests and/or x-ray of chest.
  • Check for: Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal Viscera wall muscle weakness.
  • Check for: Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins.
  • Check for: Hernias.
  • Check for: Loss or impairment of leg, foot, toe, arm, hand, finger. Perceptible limp, deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia. Insufficient grasp and prehension in upper limb to maintain steering wheel grip. Insufficient mobility and strength in lower limb to operate pedals properly.
  • Check for: Previous surgery, deformities, limitation of motion, tenderness.
  • Check for: Impaired equilibrium, coordination or speech pattern; paresthesia asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar and Babinski's reflexes, ataxia.
  • 8. PHYSICIAN; CHIROPRACTOR, PHYSICIAN ASSISTANT, OR ADVANCED PRACTICE REGISTERED NURSE COMPLETESTHIS'SECTION
  • Medical Examiners 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.) If the driver has previously been diagnosed with Stage 1, Stage 2, or Stage 3 hypertension and continues to require medication for treatment of hypertension, please indicate here and follow instructions for reduced term of medical certificate.
  • PHYSICIAN NOTE: A Doctor of Medicine (MD), Doctor of Osteopathy (DO), Physician Assistant, or Advanced Practice Registered Nurse can perform a medical examination for persons submitting a medical examination report to operate one or more of the following: School Bus, School Pupil Activity Bus, Youth Bus, General Public Paratransit Vehicle, or Farm Labor Vehicle.
  • Note certification status here. See Instructions to the Medical Examiner for guidance. I certify under penalty of perjury under the laws of the State of California that I am licensed, certified, and/or registered, in accordance with applicable State laws and regulations to perform physical examinations, that I have examined the driver named above in accordance with the Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person:
    (CHECK ALL THAT APPLY)
  • CHECK THE BOXES BELOW ONLY WHEN THE DRIVER PRESENTS ONE OF THE DOCUMENTS LISTED, A COPY OF WHICH MUST BE ATTACHED TO THIS REPORT.
  • A completed examination form is on file in my office.
  • DMV COMPLETES THIS SECTION
  • If driver meets standards, complete a Medical Examiner's Certircate according to 49 CFR 391.43 (h). (Driver must carry certificate when operating a commercial vehicle.)