Medical Examination Report Form MCSA-5875

Medical Examination Report Form MCSA-5875

U.S. Department of Transportation / FMCSA commercial driver medical certification examination report.
Driver Information and Health History
First Name

First NameLast Name
Middle Initial
Last Name

First NameLast Name
Street Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State/Province
Zip Code
Driver’s License Number
Issuing State/Province
Phone
Please enter a valid phone number.Format: (000) 000-0000.
E-Mail
example@example.com
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
CLP/CDL Applicant/Holder
MEDICAL RECORD # (or sticker)
Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?
Have you ever had surgery?
If yes, please list and explain below (surgery)
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?
If yes, please describe below (medications)
Head/brain injuries or illnesses (e.g., concussion)
Seizures/epilepsy
Eye problems (except glasses or contacts)
Ear and/or hearing problems
Heart disease, heart attack, bypass, or other heart problems
Pacemaker, stents, implantable devices, or other heart procedures
High blood pressure
High cholesterol
Chronic (long-term) cough, shortness of breath, or other breathing problems
Lung disease (e.g., asthma)
Kidney problems, kidney stones, or pain/problems with urination
Stomach, liver, or digestive problems
Diabetes or blood sugar problems
Insulin used
Anxiety, depression, nervousness, other mental health problems
Fainting or passing out
Dizziness, headaches, numbness, tingling, or memory loss
Unexplained weight loss
Stroke, mini-stroke (TIA), paralysis, or weakness
Missing or limited use of arm, hand, finger, leg, foot, toe
Neck or back problems
Bone, muscle, joint, or nerve problems
Blood clots or bleeding problems
Cancer
Chronic (long-term) infection or other chronic diseases
Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
Have you ever had a sleep test (e.g., sleep apnea)?
Have you ever spent a night in the hospital?
Have you ever had a broken bone?
Have you ever used or do you now use tobacco?
Do you currently drink alcohol?
Have you used an illegal substance within the past two years?
Have you ever failed a drug test or been dependent on an illegal substance?
Other health condition(s) not described above
Comments on health conditions (questions 1-32)
Driver’s Signature
Driver’s Signature Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Take Photo
Take Photo
Should be Empty:

Medical Examination Report Form MCSA-5875

Driver Information and Health History