Department of Transportation (DOT) Physicals

DOT Cardiovascular Form for Coronary Artery Disease and Cardiac Disease – If you have a history of MYOCARDIAL INFARCTION, HEART ATTACK, PACEMAKER, STENTS, ANGINA, CONGESTIVE HEART FAILURE, IRREGULAR HEART RHYTHM, ANEURYSM, or other HEART DISEASE print this form prior to your visit and have your cardiologist complete and supply any requested information or test results.   History of myocardial infarction (MI heart attack), cardiac stent, or other intervention, requires proof of cardiac stress testing every 2 years. History of coronary artery bypass surgery (CABG) requires yearly cardiac stress testing after 5 years. Results of stress testing and a note of clearance should be obtained from the patient’s cardiologist. Certification limit is one year.

DOT Diabetes Form – Diabetes control requires Hemoglobin A1C is less than 10.0%. Hemoglobin A1C levels above 10% may result in disqualification or shorter term of qualification. Documentation of last Hemoglobin A1C (lab results) and medication list is required. Certification limit is one year if the above criteria are met. If you have DIABETES print the form and have it completed by the physician who manages your diabetes prior to your visit. We will need a copy of your blood sugar log and your most recent (within 6 months) hemoglobin A1C value.

Please note that if you are on insulin, we will not be able to certify you.  We will provide the physical and you can apply for an exemption with the Department of Transportation.  Please print the DOT Federal Diabetes Exemption Package, complete and submit to the DOT.

DOT HTN Form: Blood pressure must be 140/90 or less on day of examination. A list of medications is required at time of examination. Certification is limited to one year if all criteria are met.  Please print the DOT HTN Form, and have your Primary Care Physician fill out prior to your DOT Physical.

DOT OSA – Obstructive Sleep Apnea/CPAP/Sleep Disorder Form: Disorders such as Obstructive Sleep Apnea (OSA) require documentation of an annual sleep evaluation with a sleep specialist. A safety-sensitive letter from your primary care physician or sleep specialist is required to document compliance with CPAP use and ability of the patient to drive his/her assigned vehicle safely. Certification limit is one year. Other sleep disorders will be evaluated on a case-by-case basis.  If you fit into this category, we require a sleep study within the last six months prior to your DOT exam.   If you have OSA, please have PCM fill out DOT OSA before the appointment.

DOT Respiratory Disease (Asthma/Chronic Obstructive Pulmonary Disease [COPD]) – If you have a history of lung disease, astham, or COPD, then please have this form filled out prior to your appointment.  You will need a spirometry or pulmonary function test (PFT) ordered prior to your DOT Clearance.

DOT Smoker Over Age 35 – If you are a smoker over the age of 35, you will need a pulmonary function test ordered prior to your DOT Clearance.  Please have your primary care physician fill out this form along with providing spirometry prior to your DOT Physical.

DOT Neurology Form for Neurological Disorders: If you have a history of STROKE, TIA, SEIZURE, or TRAUMATIC BRAIN INJURY print this form and have it completed by your neurologist prior to your visit.  Any patient with a history of stroke, seizure, or traumatic brain injury requires a safety-sensitive letter from the prescribing physician that specifically addresses the patient’s ability to operate his/her assigned vehicle safely. A letter from the patient’s neurologist documenting the patient’s date of last seizure is required. Certification limit is up to one year, at the examining physician’s discretion. If you do not have a neurologist, you will be required to have a referral from your primary care physician to a Neurologist to be evaluated.

DOT Mental Health – Patients taking anti-depressants, anti-anxiety medication, medication for ADHD, or sleeping pills require a safety-sensitive letter from the prescribing physician that specifically addresses the patient’s ability to operate his/her assigned vehicle safely. Patients must have proof of stability of their condition for at least one year from their managing physician. Please print this form and have it completed by your mental health provider prior to your visit.  Certification limit is at the examining physician’s discretion, depending on medication and medical history.

DOT Anticoagulation Form – Anticoagulation treatments such as Warfarin (Coumadin), Apixaban (Eliquis), Rivaroxaban (Xarelto), or Dabigatran (Pradaxa) have certain restrictions.  Patient must have prescribing physician fill out the form before a DOT Certification can be completed.

DOT Vision Form –  DOT guidelines require “Has distant visual acuity of at least 20/40 (Snellen) in each eye with or without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber.”  If you cannot pass your vision screen at your DOT Physical, you will need to have an Optometry exam and have this form returned to Manhattan Primary Care.

DOT Controlled Substances – If you take controlled substances like chronic narcotic pain medications, please have this form filled out prior to your appointment.