Question	Answer
Form Name	State Form 49867
Form Length	4 pages
Fillable?	Yes
Fillable fields	226
Avg. time to fill out	23 min 8 sec
Other names	indiana dot physical form, indiana cdl physical form 2021, indiana dot physical, indiana cdl physical form

				Indiana Department of Revenue
				Medical Examination Report for
		CDL-PHY		Medical Examination Report for
	State Form # 49867		Commercial Driver Fitness Determination
		(R3/10-04)
		(R3/10-04)					Commercial Driver’s License, Medical Section
							Commercial Driver’s License, Medical Section
		*Social Security Number					5252 Decatur Boulevard, Ste. R,
This state agency is requesting disclosure of your							Indianapolis, IN 46241
Social Security number, under IC 4-1-8-1, in order							Telephone: (317) 615-7335 Fax: (317) 821-2340
to perform its statutory function. Disclosure is							Telephone: (317) 615-7335 Fax: (317) 821-2340
to perform its statutory function. Disclosure is
voluntary, and you will not be penalized for refusal.
voluntary, and you will not be penalized for refusal.

1.		Driver’s Information	Driver completes this section
	Driver’s Name (Last, First, MI)				Address

	City, State, Zip Code				Age	Sex	New Certification	Work. Tel:
						M	Recertification	(	)
						F	Follow Up	Home Tel:
								(	)

State of Issue	Driver License No.	License Type		CDL Class:
		OP	CDL	A
		CH	OR	B
			(K) CDL	C

2. Health History	Driver completes this section, but medical examiner is encouraged to discuss with driver.
Yes No		Yes No	Yes	No
Any illness or injury in last 5 years?		Liver disease		Digestive problems
Head/brain injuries, disorders or illnesses		Diabetes or elevated blood sugar controlled by:
Seizures, epilepsy		diet	pills	insulin
Medication ________________________		Nervous or psychiatric disorders, e.g.; severe depression
Eye disorders, or impaired vision (except		Medication ______________________________
corrective lenses)		Loss of, or altered consciousness
Ear disorders, loss of hearing or balance		Fainting, dizziness
Heart disease or heart attack; other		Sleep disorders
cardiovascular condition		History of sleep apnea. Treatment ________________
Medication ________________________		Pauses in breathing while asleep
Heart surgery (valve replacement/bypass,		Daytime sleepiness including with driving
angioplasty, pacemaker or IC defibrillator)		Narcolepsy
High blood pressure		Loud Snoring
Medication ________________________		Insomnia/deprivation of sleep
Muscular disease		Stroke or paralysis
Shortness of breath		Missing or impaired hand, arm, foot, leg, finger, toe
Lung disease, emphysema, asthma		Spinal injury or disease		Chronic low back pain
Chronic bronchitis		Regular, frequent alcohol use
Kidney disease, dialysis		Narcotic or habit forming drug use

Driver’s Name		DL#	SS#

	Testing (Medical Examiner completes Section 3 through 7)

Acuity	Uncorrected	Corrected	Horizontal
Acuity	Uncorrected	Corrected	Field of Vision

Right Eye	20/	20/	Right Eye	°
Left Eye	20/	20/	Left Eye	°
Both Eyes	20/	20/
Both Eyes	20/	20/

Applicant can recognize and distinguish among
traffic control signals and devices showing
standard red, green and amber colors?	Yes	No
Applicant meets visual acuity requirement
only when wearing:	Corective Lenses
Monocular Visions:	Yes	No


Standard:	a) Must first perceive forced whispered voice > 5 feet with or without hearing aid, or
	b) Average hearing loss in better ear < 40dB
Check if hearding aid used for tests.		Check if hearing aid is required to meet standard.

a) Record distance from individual at which	Right Ear	Left Ear
forced whispered voice can first be heard.	Feet:	Feet:

b) If audiometer is used, record hearing	Right Ear			Left Ear
loss in decibels. (acc. to ANSI Z24.5-	500Hz	1000Hz	2000Hz	500Hz	1000Hz	2000Hz
1951)

	Average:			Average:

Blood		Systolic	Diastolic
Pressure

Driver qualified	if < 140/90 .

Pulse		Regular
Rate		Irregular

Reading	Category	Expiration Date	Recertification
140-159/90-99	Stage 1	1 year	1 year if < 140/90
			One-time certificate for 3 months
			if 140-159/90-99

160-179/100-109	Stage 2	One-time certificate for 3 months	1 year from date of exam if < 140/90

> 180/110	Stage 3	6 monts from date of exam if	6 months if <140/90 ,
		< 140/90

any underlying medical problem.		Urine	SP. GR.	Protein	Blood	Sugar
		Specimen:
Other Testing (Describe and record):
Other Testing (Describe and record):
	CDL-PHY Page 2 of 4
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Height		(in.)	Weight	(lbs.)

	Body System		Check for:		Yes No

1.		General Appearance	Marked overweight, tremor, signs of alcoholism, problem drinking,or drug abuse.
2.		Eyes	Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle
			imbalance, extraocular movement, nystagmus, exophthalmos. Ask about
			retinopathy, cataracts, aphakia, glaucoma, macular degeneration and refer to a
			specialist if appropriate.
3.		Ears	Scarring of tympanic membrane, occlusion of external canal, perforated eardrums
	4.	Mouth and Throat	Irremediable deformities likely to interfere with breathing and swallowing.
	5.	Heart	Murmurs, extra sounds, enlarged heart, pacemaker, inplantable defibrillator
6.		Lungs and chest, not including	Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath
		breast examination	sounds including wheezes or alveolar rales, impaired respiratory function,
			cyanosis. Abnormal findings on physcial exam may require further testing such
			as pulmonary tests and/or xray of chest.
7.		Abdomen and Viscera	Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal
			wall muscle weakness.
8.		Vascular system	Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins.
	9.	Genito-urinary system	Hernias.
	10.	Extremities - Limb impaired.	Loss or impairment of leg, foot, toe, arm, hand, finger.	Perceptible limp,
		Driver may be subject to SPE	deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia.
		Certificate if otherwise qualified.	Insufficient grasp and prehension in upper limb to maintain steering wheel grip.
			Insufficient mobility and strength in lower limb to operate pedals properly.
	11.	Spine, other musculoskeletal	Previous surgery, deformities, limitation of motion, tenderness.
12.		Neurological	Impaired equilibrium, coordination or speech pattern; paresthesia
			asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal
			patellar and Babinski’s reflexes, ataxia.


I certify that I have examined			in accordance with the Federal Motor Carrier Safety
Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified;
and if applicable, only when:
Wearing corrective lenses			Driving within an exempt intracity zone (49 CFR 391.62)
Wearing hearing aid			Accompnaied by a Skill performance Evaluation Cert. (SPE)
Accompanied by a		waiver/exemption		Qualified by operation of 49 CFR 391.64
The information I have	provided regarding this physical examination is true and complete. A complete
examination form with any attachment embodies my findings completely and correctly, and is on file in my
office.

Medical Certificate Expiration Date				MM	DD	YYYY

Medical Examiner’s:	Issuing State	License or Certificate No.

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