Federal Register - July 7, 2021
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Source: Federal Register
Federal Register / Vol. 86, No. 127 / Wednesday, July 7, 2021 / Rules and Regulations
35645
1633
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Firs DRiVER HEALTH HISTORY Not Veil No J;ure l. Hea 0 000 to, L!Jng disease ,e:q., asthma 15: Faihtiligtlr passing out 000 000 i 6. tilziine headaches,.num bness, tingling, or memory 0 0 0 0 0 0 0 0 0 0 0 0 a b 0 0 0 0 a 0 Othefliea_lthco.hditioti.sl rotdescribedabove: OYs 0No ONotSure f certify that the abovelnfurmation is.accurate and complete: runderstand thatcinaccurate, false or missin-gfnformation mayJnvallifate the.examination a.nd my Medial Exattrilriers Certffic ate,Jhatsu bmlsiOli of fra Date: SECTI0N2.ExaminatlonRepo,t to be /j//ed out liythe meifitalexaminer DRIVER HEALTH HISTORY REVIEW Review and discuss pertinent driver answers and anyavailable.medical records. Commenton the drivers responses to.the health history questions that may affect the drivers.safe ogeration ota commercial motor vehicle CMV. VerDate Sep<11>2014 15:58 Jul 06, 2021 Jkt 253001 PO 00000 Frm 00051 Fmt 4700 Sfmt 4725 E:FRFM07JYR1.SGM 07JYR1 ER07JY21.078 khammond on DSKJM1Z7X2PROD with RULES Attach aiiditionalsheet, ifi,etessi1ry
Doyoil h ftave you
00 0
000
000
00 0
0 0
000
000
oo a
11. Kidney problems, kidneystones;or pain/problems Withurinatlc;,n 12, Storna-c;h, li.ver, or digestive problems 13. Diabetesqrblood.sugarproblems Jnsulinusecl 14. Ahxlety, depression, nervousnesttnet mental nea:ith prol:!lems
000
000
00 0
000
lOss .
T7. Unexplafo-ed VW!ight loss H1: Stroke, mini-strokeflA, paralysis,orweakness 19. Missing Qr limited useefium, hand, finger,, leg,foot; tqe 20. Neck or l:>l!l<.prob.lems 21.. Booe, muscle, jt>int, or henie ptObleros.
2: Blood tlotsqrbleeding prolilems 23,Canter 24. Chronic: long-term infection ofother chronic di$eases 25", Sleepdimldel.i1,pau,e,; in breatfiliig.whlleasleep;
daytitnesleapfness, loudsnoring 26. Have you erhad atleeptest /eg., sfeepnprie:d?
27. Haveyi,ueverspent hight in thelit>spiial, is. t:1ave01teverhada broken bQhe?
:29. Have you:ev!!tUS!!tl or clo.yciu now use tobacco?
30. tioyou currenHy.drinkakohol?
31, Haf& yo usi,q ah illega I substance 111/ithln the past
twoyears?
32, Hav!! you ever failed a drug test or be;;n dependent
on.an illegal ,.ubstance?
0 0 0
0 0 0
0 0 0
0
0
0 0 0
0 0 0
0 0 0
0 0 0
0 0 0
0 0
0 0
0
Did.y<;iu anSiifli!ryes"to any:of questions 13?? lf,o. piease i::om ment further on mse health conditions below:
CMV DRIVERS SIGNATURE
Driver!; Signature:
