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Federal Register / Vol. 86, No. 127 / Wednesday, July 7, 2021 / Rules and Regulations
35645

1633
Fann l/fCsiv.;as
I

Lastillame: _ _ _ _ _ _ _ _ _ __

Firs

DRiVER HEALTH HISTORY

Not
Doyoil h ftave you

Veil No J;ure
00 0

l. Hea4. Ear and/or hearing problems s. Heart d1$ease, heart arttack, byps!l; or 000
000
000
00 0
0 0

0

000
000
000

to, L!Jng disease ,e:q., asthma
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

15: Faihtiligtlr passing out
000
00 0

000

000
000

i 6. tilziine headaches,.num bness, tingling, or memory 0
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

a
0 0 0
0 0 0

b 0 0
0 0 0
0 0 0
0 0 0
0 0
0 0

0
0

0 a 0

Othefliea_lthco.hditioti.sl rotdescribedabove:

OYs 0No
Did.y<;iu anSiifli!ryes"to any:of questions 13?? lf,o. piease i::om ment further on mse health conditions below:

ONotSure
CMV DRIVERS SIGNATURE

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 fraof fraudulent or lntE!ntlonatlyfalseinformation mi,y sobjeameto civil or criminal penaltiE!S under 4!tCfll390.lt2 andAppendicE!S Aand B.
Driver!; Signature:

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

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