Medical Examination Report Form

Form MCSA-5875
OMB No.: 2126-0006 Expiration Date: 03/31/2025
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)
PERSONAL INFORMATION

SECTION 1. Driver Information(to be filled out by the driver)
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Age*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
State/Province*
Zip Code*
Driver’s License Number*
Issuing State/Province*
Phone*
E-Mail (optional)
example@example.com
CLP/CDL Applicant/Holder*:*

YesNo
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?*

YesNoNot Sure
DRIVER HEALTH HISTORY
Have you ever had surgery? If “yes,” please list and explain below.*

YesNoNot Sure
If “yes,” please list and explain below. Type of surgery and year performed.*
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If “yes,” please describe below.*

YesNoNot Sure
If “yes,” please describe below. Name your medications.*
**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.**
Form MCSA-5875
OMB No.: 2126-0006 Expiration Date: 03/31/2025

	Yes	No	Not 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, 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 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?

Other health condition(s) not described above? If so, please comment further on those health conditions below:*

YesNoNot Sure
Please comment further on those health conditions below: Name those conditions*
Did you answer “yes” to any of questions 1-32? If so, please comment further on those health conditions below:*

YesNoNot Sure
Please comment further on those health conditions below:*
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.
Should be Empty:

Medical Examination Report Form

PERSONAL INFORMATION

DRIVER HEALTH HISTORY