Form MCSA-5875 Medical Examination Report Form

  • The information that you provide here will be populated into the official MCSA-5875 Medical Examination Report Form (the Long Form) and sent securely to our clinic after you submit it.

    You can Save and then Resume this Form at any time by clicking on the "Save" button at the end of the Form. Our Provider will go over the Form with you and complete a Physical Exam when you arrive at our clinic.

    You can also download the MCSA-5875 Form here as provided by the FMCSA.

     

  • Form MCSA-5875

  • Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?*
  • Have you ever had surgery?*
  • Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?*

  • Form MCSA-5875

  • Do you have or have you ever had:

  • 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*
  • 13. Insulin Use*
  • 14. Anxiety, depression, nervousness, other mental health problems*
  • 15. Fainting or passing out*

  • Form MCSA-5875

  • Do you have or have you ever had:

  • 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 (long-term) infection or other chronic diseases*
  • 25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring*
  • 26. Have you ever had a sleep test (e.g., sleep apnea)?*
  • 27. Have you ever spent a night in the hospital?*
  • 28. Have you ever had a broken bone?*
  • 29. Have you ever used or do you now use tobacco?*
  • 30. Do you currently drink alcohol?*
  • 31. Have you used an illegal substance within the past two years?*
  • 32. Have you ever failed a drug test or been dependent on an illegal substance?*

  • Form MCSA-5875

  • Other health condition(s) not described above:*
  • Did you answer "yes" to any of questions 1-32? (You can click the Back button at the bottom of the Form to see your previous answers, information that you provided will be saved)*

  • I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner’s Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.

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