Demo Exam
  • History
  • Review
  • Testing
  • Exam
  • Determination




Employment Status
Work Status

Employer Info

ID / Verification

ID Type
Issuing Entity
CLP/CDL Applicant/Holder
Has your medical cert. ever been denied or issued for less than 2 years?
CDL Clearance Type
The issuing State / Province requires this information to submit your results to the DMV. Please select one of the options above.

Maximum file size: 516MB

New Hampshire requires a photo of a current CDL / License in order to complete the state submittal. If uploaded, this will be included with your certificate with each completed exam.


Have you ever had surgery?

Medications / Supplements

Are you currently taking medications or supplements?

Health History

Do you have or have you ever had:


1. Head / brain injuries or illnesses (e.g. concussion)
When? How many instances? Loss of consciousness?
2. Seizures / epilepsy
Currently taking anti-seizure medications? Please describe
3. Eye problems (except glasses or contacts)
Cataracts? Glaucoma? Retinopathy?
4. Ear and / or hearing problems
Partial hearing loss? Vertigo? Balance issues? Tinnitus?
5. Heart disease, heart attack, bypass, or other heart problems
Please describe
6. Pacemaker, stents, implantable devices, or other heart procedures
Please describe
7. High blood pressure
How many years? Medications used?
8. High cholesterol
How many years? Medications used?
9. Chronic (long-term) cough, shortness of breath, or other breathing problems
Please describe
10. Lung disease (e.g., asthma)
Please describe
11. Kidney problems, kidney stones, or pain / problems with urination
Please describe
12. Stomach, liver, or digestive problems
Please describe
13. Diabetes or blood sugar problems
If applicable, please enter your most current A1C score below.
13a. Have you had a hypoglycemic episode in the last year?
If yes, accompanied by any of the following?
Check all that apply.
13b. Insulin used?
14. Anxiety, depression, nervousness, other mental health problems
Current or past? Medications used?
15. Fainting or passing out
Known triggers? Frequency?
16. Dizziness, headaches, numbness, tingling, or memory loss
Please describe


17. Unexplained weight loss
How much weight? Over what time frame?
18. Stroke, mini-stroke (TIA), paralysis, or weakness
Please describe
19. Missing or limited use of arm, hand, finger, leg, foot, toe
Diminished range of motion or grip? Work modifications?
20. Neck or back problems
Chronic pain? Scoliosis? Disc herniations?
21. Bone, muscle, joint, or nerve problems
Arthritic conditions? Muscle spasms? Neuropathy?
22. Blood clots or bleeding problems
Please describe
23. Cancer
Please describe
24. Chronic (long-term) infection or other chronic diseases
Please describe
25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
Sleep apnea? What form of treatment to you use?
If you are using a CPAP, do you have usage data?
Please provide a copy (.jpg, .png, .pdf or printed) for your examiner to upload on the following page.
26. Have you ever had a sleep test (e.g., sleep apnea)?
Sleep test result? How many years ago?
27. Have you ever spent a night in the hospital?
Please describe
28. Have you ever had a broken bone?
What bone did you break? Surgery required? Extended recovery time?
29. Have you ever used or do you now use tobacco?
Type? Frequency? How many years?
30. Do you currently drink alcohol?
31. Have you used an illegal substance within the past two years?
Please describe
32. Have you ever failed a drug test or been dependent on an illegal substance?
Please describe