Intake Mode
Intake

Patient

Name
DOB

Contact

Phone
Email
Address
Country
+4
SSN
Alerts?
Employment Status
Work Status

Employer

(optional)

ID / Verification

ID Type
Entity
DL#
Exp.
CLP/CDL Applicant/Holder
CLP/CDL Applicant/Holder
CDL Clearance Type
CDL Clearance Type
Has your USDOT/FMCSA medical cert. ever been denied or issued for less than 2 years?
Has your med card been denied or issued < 2 years?

Surgeries

Have you ever had surgery?

Medications / Supplements

Are you currently taking medications or supplements?

Health History

Do you have or have you ever had:

Hx1

1. Head / brain injuries or illnesses (e.g. concussion)
1. Checkboxes
How severe was your TBI / Concussion?
2. Seizures / epilepsy
How many instances?
Are you taking anti-seizure medication?
How long has it been since your last seizure?
3. Eye problems (except glasses or contacts)
3. Checkboxes
4. Ear and / or hearing problems
4. Checkboxes
5. Heart disease, heart attack, bypass, or other heart problems
5. Checkboxes
What type of Heart Valve Condition?
6. Pacemaker, stents, implantable devices, or other heart procedures
6. Checkboxes
7. High blood pressure
Do you currently manage hypertension with medication?
8. High cholesterol
Do you currently manage cholesterol with medication?
9. Chronic (long-term) cough, shortness of breath, or other breathing problems
9. Checkboxes
10. Lung disease (e.g., asthma)
10. Checkboxes
11. Kidney problems, kidney stones, or pain / problems with urination
11. Checkboxes
12. Stomach, liver, or digestive problems
12. Checkboxes
13. Diabetes or blood sugar problems
13b. Insulin used?
14. Anxiety, depression, nervousness, other mental health problems
14. Checkboxes
15. Fainting or passing out
16. Dizziness, headaches, numbness, tingling, or memory loss
16. Checkboxes

Hx2

17. Unexplained weight loss
18. Stroke, mini-stroke (TIA), paralysis, or weakness
18. Checkboxes
19. Missing or limited use of arm, hand, finger, leg, foot, toe
19. Checkboxes
20. Neck or back problems
20. Checkboxes
21. Bone, muscle, joint, or nerve problems
21. Checkboxes
22. Blood clots or bleeding problems
22. Checkboxes
23. Cancer
24. Chronic (long-term) infection or other chronic diseases
24. Checkboxes
25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
25. Checkboxes
26. Have you ever had a sleep test (e.g., sleep apnea)?
27. Have you ever spent a night in the hospital?
28. Have you ever had a broken bone?
29. Have you ever used or do you now use tobacco?
30. Do you currently drink alcohol?
31. Have you used an illegal substance within the past two years?
32. Have you ever failed a drug test or been dependent on an illegal substance?

Applicable Clearance Letters:

Select each clearance letter you would like to use from the list below. Addressing these beforehand will reduce the risk of an incomplete exam and help to ensure your certification.