Drivers | Doctors | Standards / Forms  | Consultation | Contact  DOT MEDICAL INFORMATION for professional drivers

Confidential Consultation & Practice DOT Medical Test

 Contact TRUCKMED

Fill out the form below to establish your eligibility for DOT medical certification
Will you pass your next DOT physical?  Know before you go!

 All information is held strictly confidential and no information will be divulged to anyone without your consent. This form is designed to identify areas which may jeopardize DOT certification or that will require extensive documentation prior to approval. This screening tool should not be used as a substitute for a physicians examination or advice. 
 
Name 
Age       Gender
E-mail Address
Confirm Email		 Valid e-mail required
 Has your DOT medical been denied,                     
suspended or revoked?                
 

 

 

 

         If "YES", please give details below.
Date of last medical application   No prior application

 

                   Medication

   Dosage  Condition Treated
Detail any loss of consciousness, injuries, major surgeries, or other condition which might limit physical activity or safety.

Select all below which applies (Explain in the box below)
Frequent or severe headaches
Eye or vision trouble
Hay fever or allergy
Asthma or lung disease
Stomach, liver, or intestinal trouble
Kidney stone or blood in urine
Neurological: epilepsy, seizures, stroke, etc
Mental disorders: depression, anxiety, etc
Dependence on or use of illegal substance
Alcohol dependence, abuse or related convictions
Suicide attempt
Motion sickness requiring medication
Dizziness, fainting spells, or unconsciousness
Sleep Disorder: sleep apnea, narcolepsy, etc
EXPLAIN

 

 

Diabetes?

HEART HISTORY
Myocardial Infarction (Heart Attack)
Angina, bypass, angioplasty
Stroke / blood vessel surgery
Other heart condition    List
Blood Pressure

          

 

We help truckers and other professional drivers with DOT medical certification issues.

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TRUCKMED  Providing Solutions for Pilots & Professional Drivers Since 1995