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DOT Physical Form

A DOT physical form, also known as a Department of Transportation physical form, is a standardized document used to assess the physical fitness of commercial motor vehicle drivers to ensure they meet the health and safety requirements necessary for operating commercial vehicles on public roads. This form is typically completed by a certified medical examiner and includes details about the driver's health, medical history, and physical examination results.

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.

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U.S. Department of Transportation

Federal Motor Carrier

Safety Administration

Medical Examination Report Form

(for Commercial Driver Medical Certification)

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


(or sticker)


*CLP/CDL Applicant/Holder: See instructions for definitions
**Driver ID Verified By: Record what type of photo ID was used to verify the identity of the driver, e.g., CDL, driver’s license, passport

If “yes,” please list and explain below

If “yes,” please describe below.

**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.**

Last Name: First Name: DOB: Exam Date:


Do you have or have you ever had:



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. Diabetes or blood sugar problems Insulin used

15. Fainting or passing out

16. Anxiety, depression, nervousness, other mental health problems



Not Sure

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?

If so, please comment further on those health conditions below: