Demo Exam HistoryReviewTestingExamDetermination Patient Name * Name Name (middle) Name (last) * Name (suffix) ...Jr.Sr.2nd3rdIIIIIIVVVI Date of Birth DOB Age Contact Phone Phone Email Email Address * Address Address (line 2) Address (city) * City Country Country United StatesCanada State * State AKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Address (zip) * Zip Address (+4) +4 Province * Province ABBCMBNBNLNSONPEQCSK Address (pc) * Postal SSN SSN Would you like to receive notifications? Alerts? Get expiration alertsOpt-out Employment Status Work Status EmployedOwner / OpUnemployed Employer Info plus minus Company Name Company Company Contact Mgr. Company Email Mgr. Email Company Fax Mgr. Fax Copy Employer on Emails Mgr. Alerts? Copy employer on emailsOpt-out ID / Verification Driver ID Verified By ID Type CDLdriver's licensepassportother picture ID Issuing Entity * Issuing Entity AlabamaCaliforniaWest Virginia Driver's License Number DL# CLP/CDL Applicant/Holder YesNo Has your medical cert. ever been denied or issued for less than 2 years? YesNoNot Sure CDL Clearance Type * Non-Excepted InterstateExcepted Interstate (school bus, etc)Non-Excepted Intrastate (STATE)Excepted Intrastate (STATE) The issuing State / Province requires this information to submit your results to the DMV. Please select one of the options above. CDL Photo (optional) Upload Upload 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. License Expiration Date Surgeries Have you ever had surgery? NoNot SureYes Please select from this list of procedures. For anything not listed use the text box below: + Amputation (arm)Amputation (foot)Amputation (hand)Amputation (leg)AngioplastyAnkle replacementAnkle surgeryAppendix removedAtherectomyBack surgeryBiopsyBrain SurgeryBroken bone repairCarpal Tunnel releaseCataract surgeryC-sectionGallbladder RemovedCoronary Artery Bypass (CABG)Debridement (wound, burn, infection)Foot surgeryFree skin graftFusionGastric BypassHand surgeryHeart TransplantHemorrhoidectomyHernia repairHip replacementHip surgeryHysterectomyHysteroscopyKnee replacementKnee surgeryLasik surgeryMastectomyMitral Valve RepairPacemaker placementPartial colectomyPercutaneous Coronary Intervention (PCI)Prostate RemovedProsthetic Valve ReplacementShoulder surgeryShoulder replacementStent placementTonsillectomyTranscatheter Aortic Valve Replacement (TAVR) Surgeries: Additional Notes Medications / Supplements Are you currently taking medications or supplements? NoNot SureYes Please select from this list of medications. For anything not listed use the text box below: + Dietary SupplementHerbal Remedies----Most Commonly Prescribed----Atorvastatin (Lipitor)LevothyroxineLisinoprilMetforminMetoprololAmlodipineAlbuterolOmeprazoleLosartanGabapentinHydrochlorothiazideSertraline (Zoloft)Simvastatin (Zocor)Montelukast (Singulair)Acetaminophen; HydrocodonePantoprazoleFurosemideFluticasoneEscitalopramFluoxetineRosuvastatinBupropion (Wellbutrin)AmoxicillinTrazodoneTrulicityOzempicDuloxetine (Cymbalta)PrednisoneTamsulosin (Flomax)IbuprofenCitalopramMeloxicamPravastatinCarvedilolTramadolClopidogrel (Plavix)Glargine InsulinAspart InsulinAspirinAtenololByettaVenlafaxine (Effexor)AlprazolamLamotrigineEthinyl EstradiolAllopurinolCyclobenzaprine (Flexeril)----Alphabetical List----AbilifyAciphexActosAcyclovirAdderallAdderall XRAdvair DiskusAdvilAlendron (Fosamax)Alphagan PAmbienAmbien - Extended ReleaseAmiodaroneAmitriptylineAmoxapineAmoxilAmoxil (Trimox)Amphetamine Mixed SaltsAnticonvulsant (Seizures)AntihistaminesArmour ThyroidAstelinAstramorphAtivanAugmentin XRAvalideAveloxAzithromycinAzithromycin (Zithromax)AzoptBaclofenBasalglar InsulinBenazeprilBenicarBenicar HCTBenzaClinBenzodiatineBenzonatateBenztropineBisoprolol/HctBisoprolol/HCTZBromocriptinBudesonide Inhalation Suspension (Pulmicort Respules)Budesonide Nasal Spray (Rhinocort Aqua)Buporpion HCLBuspirone (Buspar)ByettaCabergolineCandesartan Cilexetil (Atacand)CaptoprilCarbamazepineCarbidopa-LevodopaCarisoprodolCBD OilCefdinivir (Omnicef)CefuroximeCefzilCelecoxib Capsules (Celebrex)Celexa (SSRI)CephalexinCerebyx-PhenytoinCetirizine (Zyrtec Syrup)Cetririzine (Zyrtec Tablets)ChantixChlorhexidine GluconateCialisCiprofloxacinClarinexClarithromycin (Biaxin XL)Claritin DClindamycinClindamycin (Topical)ClinorilClobazamClobetasolClomidClomipramineClonazepamClonidineClotrimazole/BetamethasoneCodeineColchicineCombiventConjugated Estrogens (Premarin)Conjugated Estrogens/Medroxyprogesterone Acetate (Prempro)ConZipCoregCosartinCrestorDepodurDesipramineDiastatDiastat AcudialDiazepamDiclofenacDicyclomineDigoxinDigoxin (Digitek)Digoxin (Lanoxin)DilantinDiltiazem CDDiltiazem Hydrochloride (CartiaXT)Diltiazem SRDiovan HCTDiphenoxylate/AtropineDitropan XLDivalproex Sodium (Depakote ER)Divalproex Sodium (Depakote)DlorazepateDonepezil Hydrochloride (Aricept)DoramorphDorzolamide Hydrochloride-Timolol Maleate Opthalmic Solution (Cosopt)DoxazosinDoxepinDoxycyclineEdluarEffientElidelEliquis (apixaban)EnalaprilEnbrelEsomeprazole Magnesium (Nexium)EstradiolEstradiol Transdermal System (Vivelle-DOT)Estrostep FeEtodolacEzetimibe (Zetia)FamotidineFarxigaFenofibrate (Tricor)FentanylFexofenadineFexofenadine (Allegra)Fexofenadine HCI and Pseudoephedrine HCI (Allegra-D 12 Hour)Finasteride (Proscar)FlonaseFlovent HFAFluconazoleFluocinonideFluvastatin Sodium (Lescol XL)Folic AcidFortametFosamax, AlendronFosinoprilGemfibrozilGlimeperideGlimepiride (Amaryl)GlipizideGlipizide ERHalcionHCTZHemp OilHumalog InsulinHumulinHumulin 70/30Humulin NHycotuss ExpectorantHydralazineHydralazine HCLHydrocodoneHydrocodone Polistirex and Chlorpheniramine Polistirex (Tussionex)HydrocortisoneHydroxychloroquineHydroxyzineHyoscyamineImipramineInderal LAIndomethacinIntermezzoInvokanaIrbesartan (Avapro)IsocarboxazidIsosorbideJanuviaJardianceKetekKetoconazoleKlonopinKlor-ConKombiglyzeKoregKratomLabetalolLamictalLamotrigineLansoprazole (Prevacid)Lantus InsulinLatanoprost Ophthalmic Solution (Xalatan)Levalbuterol HCI (Xopenex)LevaquinLevemir InsulinLevitraLevothroidLevothyroxine Sodium (Synthroid)LevoxylLexaproLidodermLipitorLithium CarbonateLorazepamLortabLotrelLovastatinLunestaLunesta - Extended ReleaseLyricaMeclizineMedroxyprogesteroneMedical MarijuanaMetaxalone (Skelaxin)MethadoneMethocarbamolMethotrexateMethylphenidate HCI (Concerta)MethylprednisoloneMetoclopramideMetorolol Succinate (Toprol-XL)Metronidazole TabsMinocyclineMirtazapineMobicMorphineMotrinMupirocinMupirocin (Bactroban)Musinex DMNabumetoneNamendaNaproxenNaproxen SodiumNasonexNexiumNiaspanNifedipine ERNiravamNitrofurantoinNitroglycerinNitroquickNortriptylineNovolog InsulinNuvaRingNystatinNystatin (Topical)Olanzapine (Zyprexa)Olopatadine Hydrochloride (Patanol)OnfiOnglyzaOrtho EvraOseltamivir Phosphate (Tamiflu)OTC AlergyOTC Cold medOTC diet pillsOTC VitaminsOxazepamOxcarbazepine (Trileptal)OxectaOxybutyninOxycodoneOxyContinOzempicParcopaParoxetinePaxil CRPenicillin VKPercocetPhenazopyridinePhenelzinePhenobarbitalPhentermine (no adverse effects)PhenytecPhenytec-PhenytoinPhenytoinPhenytoin Sodium (Dilantin)Pioglitazone Hydrochloride (Actos)PiroxicamPolyethylene Glycol (Glycolax)Potassium ChloridePradaxa (dabigatran)PravacholPrednisolonePrilosecPromethazinePromethazine DMPromethazine/CodeinePrometriumPropranololProtonixProtriptylineProvigil (modafinil)ProzacQuetiapine Fumarate (Seroquel)QuinaprilQuinineRaloxifene Hydrochloride (Evista)Ramipril (Altace)RanitidineRemeron (mirtazapine) - taken QHSRequip (Ropinirole)RestorilRisedronate Sodium (Actonel)RisperdalRitalinRosiglitazone Maleate (Avandia)RoxicodoneRyzoltSelegilineSeraxSinemetSonata (zaleplon) - taken QHSSpirivaSpironolactoneStatinStratteraSuboxone (buprenorphine)SudafedSumatriptan Succinate (Imitrex)SymbicortSynthroidTamoxifenTanzeumTemazepamTerazosinTervinafine Hydrochloride (Lamisil)TetracyclineTizanidineTobradexTolterodine Tartrate (Detrol LA)TopamaxToujeo InsulinTradjentaTranylcypromineTranxeneTranxene SDTresiba InsulinTriamcinlnoloneTriamcinolone Acetonide (Nasacort AQ)TriazolamTrimethoprim/SulfamethoxazoleTrimipramineTrivora-28TrulicityTylenolUloricUltracetUltramValiumValium (Diazepam)Valsartan (Diovan)ValtrexVerapamil SRViagraVicodinVicoprofenVictozaVigamoxVistarilVivitrol (naltrexone)VytorinWarfarinWarfarin (Coumadin)XanaxXanax XRXarelto (rivaroxaban)YasminZelnormZestoreticZolpidemZolpidem Tartrate (Ambien)ZolpimistZyrtec-D Medications: Additional Notes Health History Do you have or have you ever had: Hx1 1. Head / brain injuries or illnesses (e.g. concussion) NoNot SureYes 1. Explain * ( 1. ) Head injury. When? How many instances? Loss of consciousness? 2. Seizures / epilepsy NoNot SureYes 2. Explain * ( 2. ) Seizure. Currently taking anti-seizure medications? Please describe 3. Eye problems (except glasses or contacts) NoNot SureYes 3. Explain * ( 3. ) Eye problem. Cataracts? Glaucoma? Retinopathy? 4. Ear and / or hearing problems NoNot SureYes 4. Explain * ( 4. ) Ear problem. Partial hearing loss? Vertigo? Balance issues? Tinnitus? 5. Heart disease, heart attack, bypass, or other heart problems NoNot SureYes 5. Explain * ( 5. ) Heart problem. Please describe 6. Pacemaker, stents, implantable devices, or other heart procedures NoNot SureYes 6. Explain * ( 6. ) Heart procedure. Please describe 7. High blood pressure NoNot SureYes 7. Explain * ( 7. ) High blood pressure. How many years? Medications used? 8. High cholesterol NoNot SureYes 8. Explain * ( 8. ) High cholesterol. How many years? Medications used? 9. Chronic (long-term) cough, shortness of breath, or other breathing problems NoNot SureYes 9. Explain * ( 9. ) Breathing problem. Please describe 10. Lung disease (e.g., asthma) NoNot SureYes 10. Explain * ( 10. ) Lung disease. Please describe 11. Kidney problems, kidney stones, or pain / problems with urination NoNot SureYes 11. Explain * ( 11. ) Kidney problem. Please describe 12. Stomach, liver, or digestive problems NoNot SureYes 12. Explain * ( 12. ) Digestive problem. Please describe 13. Diabetes or blood sugar problems NoNot SureYes 13. Explain * ( 13. ) Diabetic. If applicable, please enter your most current A1C score below. A1C Score 4 13a. Have you had a hypoglycemic episode in the last year? * No Yes If yes, accompanied by any of the following? The need for assistance of another individual The loss of consciousness or coma Seizure Check all that apply. 13b. Insulin used? NoNot SureYes 13b. Explain * ( 13b. ) Insulin use. 14. Anxiety, depression, nervousness, other mental health problems NoNot SureYes 14. Explain * ( 14. ) Mental health problem. Current or past? Medications used? 15. Fainting or passing out NoNot SureYes 15. Explain * ( 15. ) Fainting. Known triggers? Frequency? 16. Dizziness, headaches, numbness, tingling, or memory loss NoNot SureYes 16. Explain * ( 16. ) Please describe Hx2 17. Unexplained weight loss NoNot SureYes 17. Explain * ( 17. ) Unexplained weight loss. How much weight? Over what time frame? 18. Stroke, mini-stroke (TIA), paralysis, or weakness NoNot SureYes 18. Explain * ( 18. ) Ischemic event. Please describe 19. Missing or limited use of arm, hand, finger, leg, foot, toe NoNot SureYes 19. Explain * ( 19. ) Limb impairment. Diminished range of motion or grip? Work modifications? 20. Neck or back problems NoNot SureYes 20. Explain * ( 20. ) Back problem. Chronic pain? Scoliosis? Disc herniations? 21. Bone, muscle, joint, or nerve problems NoNot SureYes 21. Explain * ( 21. ) Arthritic conditions? Muscle spasms? Neuropathy? 22. Blood clots or bleeding problems NoNot SureYes 22. Explain * ( 22. ) Bleeding problem. Please describe 23. Cancer NoNot SureYes 23. Explain * ( 23. ) Cancer. Please describe 24. Chronic (long-term) infection or other chronic diseases NoNot SureYes 24. Explain * ( 24. ) Chronic infection or disease. Please describe 25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring NoNot SureYes 25. Explain * ( 25. ) Sleep disorder. Sleep apnea? What form of treatment to you use? If you are using a CPAP, do you have usage data? * Yes No 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)? NoNot SureYes 26. Explain * ( 26. ) I have had a sleep test. Sleep test result? How many years ago? 27. Have you ever spent a night in the hospital? NoNot SureYes 27. Explain * ( 27. ) Hospitalized. Please describe 28. Have you ever had a broken bone? NoNot SureYes 28. Explain * ( 28. ) Broken bone. What bone did you break? Surgery required? Extended recovery time? 29. Have you ever used or do you now use tobacco? NoNot SureYes 29. Explain * ( 29. ) Tobacco use. Type? Frequency? How many years? 30. Do you currently drink alcohol? NoNot SureYes 30. Explain * ( 30. ) Alcohol use. Frequency? 31. Have you used an illegal substance within the past two years? NoNot SureYes 31. Explain * ( 31. ) Illegal substance use. Please describe 32. Have you ever failed a drug test or been dependent on an illegal substance? NoNot SureYes 32. Explain * ( 32. ) Failed drug test. Please describe If you are human, leave this field blank. Review