Intake Mode Intake 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) * Country * CountryUnited StatesCanada State * StateAKALARAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVTWAWIWVWY Address (zip) * Address (+4) +4 Province * ProvinceABBCMBNBNLNSONPEQCSK Address (pc) * SSN SSN Would you like to receive notifications? Alerts? Get expiration alertsOpt-out Employment Status Work Status EmployedOwner / OpUnemployed Employer plus minus (optional) Company Name Company Company Contact Contact Company Email Email Company Fax 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 * State AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingAlbertaBritish ColumbiaManitobaNew BrunswickNewfoundlandNorthwest TerritoriesNova ScotiaOntarioPrince Edward IslandQuebecSaskatchewanYukonOther Entity Driver's License Number DL# License Expiration Date Exp. CLP/CDL Applicant/Holder CLP/CDL Applicant/Holder YesNo CDL Clearance Type * CDL Clearance Type NoneNon-Excepted Interstate (most common)Excepted Interstate (school bus, etc)Non-Excepted Intrastate (STATE)Excepted Intrastate (STATE) 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? YesNoNot Sure Surgeries Have you ever had surgery? NoNot SureYes Surgeries Repeater Please select from this list of procedures: Select from this list of proceduresAbdominal Aortic Aneurysm repairACL repairAdenoid removalAmputation (arm)Amputation (foot)Amputation (hand)Amputation (leg)AngioplastyAnkle replacementAnkle surgeryAppendix removedArterial plaque removalBack surgeryBiopsyBladder surgeryBrain surgeryBroken bone repairC-sectionCardiac ablationCarpal tunnel releaseCataract surgeryCochlear implantColon partial removalColonoscopyCoronary artery bypass (CABG)Debridement (wound, burn, infection)Fallopian tube removedFibroid removedFoot surgeryFree skin graftFusionGallbladder removedGastric bypassHand surgeryHeart transplantHemorrhoid removalHernia repairHip replacementHip surgeryHysteroscopyKidney removedKnee replacementKnee surgeryLaminectomyLasik surgeryLiver partial removalLung partial removalMastectomyMitral valve repairNasal septum surgeryNeck surgeryNerve decompressionNose surgeryOvary removalPacemaker placementParathyroid removalPercutaneous coronary intervention (PCI)Prostate removedProsthetic valve replacementReflux surgeryShoulder replacementShoulder surgerySpinal disc partial removalSpinal fusionSpleen removedStent placementThyroid removedTonsils removedTooth removedTranscatheter aortic valve replacement (TAVR)Uterus removedVasectomyWeight loss surgeryCustom (other) Please select from this list of procedures: Procedure note Procedure statement plus minus Medications / Supplements Are you currently taking medications or supplements? NoNot SureYes Medications / Supplements Repeater Please select from this list of medications: Select from this list of medicationsAbilifyAcetaminophen; HydrocodoneAciphexActosAcyclovirAdderall XRAdderallAdvair DiskusAdvilAlbuterolAlendron (Fosamax)AllopurinolAlphagan PAlprazolamAmbien - Extended ReleaseAmbienAmiodaroneAmitriptylineAmlodipineAmoxapineAmoxicillinAmoxil (Trimox)Amphetamine Mixed SaltsAnticonvulsant (Seizures)AntihistaminesArmour ThyroidAspart InsulinAspirinAstelinAstramorphAtenololAtivanAtorvastatin (Lipitor)Augmentin XRAvalideAveloxAzithromycin (Zithromax)AzoptBaclofenBasalglar InsulinBenazeprilBenicar HCTBenicarBenzaClinBenzodiatineBenzonatateBenztropineBisoprolol/HctBisoprolol/HCTZBromocriptinBudesonide Inhalation Suspension (Pulmicort Respules)Budesonide Nasal Spray (Rhinocort Aqua)Buporpion HCLBupropion (Wellbutrin)Buspirone (Buspar)ByettaCabergolineCandesartan Cilexetil (Atacand)CaptoprilCarbamazepineCarbidopa-LevodopaCarisoprodolCarvedilolCBD OilCefdinivir (Omnicef)CefuroximeCefzilCelecoxib Capsules (Celebrex)Celexa (SSRI)CephalexinCerebyx-PhenytoinCetirizine (Zyrtec Syrup)Cetririzine (Zyrtec Tablets)ChantixChlorhexidine GluconateCialisCiprofloxacinCitalopramClarinexClarithromycin (Biaxin XL)Claritin DClindamycin (Topical)ClindamycinClinorilClobazamClobetasolClomidClomipramineClonazepamClonidineClopidogrel (Plavix)Clotrimazole/BetamethasoneCodeineColchicineCombiventConjugated Estrogens (Premarin)Conjugated Estrogens/Medroxyprogesterone Acetate (Prempro)ConZipCoregCosartinCrestorCyclobenzaprine (Flexeril)DepodurDesipramineDiastat AcudialDiastatDiazepamDiclofenacDicyclomineDietary SupplementDigoxin (Digitek)Digoxin (Lanoxin)DigoxinDilantinDiltiazem CDDiltiazem Hydrochloride (CartiaXT)Diltiazem SRDiovan HCTDiphenoxylate/AtropineDitropan XLDivalproex Sodium (Depakote ER)Divalproex Sodium (Depakote)DlorazepateDonepezil Hydrochloride (Aricept)DoramorphDorzolamide Hydrochloride-Timolol Maleate Opthalmic Solution (Cosopt)DoxazosinDoxepinDoxycyclineDuloxetine (Cymbalta)EdluarEffientElidelEliquis (apixaban)EnalaprilEnbrelEscitalopramEsomeprazole Magnesium (Nexium)Estradiol Transdermal System (Vivelle-DOT)EstradiolEstrostep FeEthinyl EstradiolEtodolacEzetimibe (Zetia)FamotidineFarxigaFenofibrate (Tricor)FentanylFexofenadine (Allegra)Fexofenadine HCI and Pseudoephedrine HCI (Allegra-D 12 Hour)FexofenadineFinasteride (Proscar)FlonaseFlovent HFAFluconazoleFluocinonideFluoxetineFluticasoneFluvastatin Sodium (Lescol XL)Folic AcidFortametFosamax, AlendronFosinoprilFurosemideGabapentinGemfibrozilGlargine InsulinGlimeperideGlimepiride (Amaryl)Glipizide ERGlipizideHalcionHCTZHemp OilHerbal RemediesHumalog InsulinHumulin 70/30Humulin NHumulinHycotuss ExpectorantHydralazine HCLHydralazineHydrochlorothiazideHydrocodone Polistirex and Chlorpheniramine Polistirex (Tussionex)HydrocodoneHydrocortisoneHydroxychloroquineHydroxyzineHyoscyamineIbuprofenImipramineInderal LAIndomethacinIntermezzoInvokanaIrbesartan (Avapro)IsocarboxazidIsosorbideJanuviaJardianceKetekKetoconazoleKlonopinKlor-ConKombiglyzeKoregKratomLabetalolLamictalLamotrigineLansoprazole (Prevacid)Lantus InsulinLatanoprost Ophthalmic Solution (Xalatan)Levalbuterol HCI (Xopenex)LevaquinLevemir InsulinLevitraLevothroidLevothyroxine Sodium (Synthroid)LevothyroxineLevoxylLexaproLidodermLipitorLisinoprilLithium CarbonateLorazepamLortabLosartanLotrelLovastatinLunesta - Extended ReleaseLunestaLyricaMeclizineMedical MarijuanaMedroxyprogesteroneMeloxicamMetaxalone (Skelaxin)MetforminMethadoneMethocarbamolMethotrexateMethylphenidate HCI (Concerta)MethylprednisoloneMetoclopramideMetoprololMetorolol Succinate (Toprol-XL)Metronidazole TabsMinocyclineMirtazapineMobicMontelukast (Singulair)MorphineMotrinMupirocin (Bactroban)MupirocinMusinex DMNabumetoneNamendaNaproxen SodiumNaproxenNasonexNexiumNiaspanNifedipine ERNiravamNitrofurantoinNitroglycerinNitroquickNortriptylineNovolog InsulinNuvaRingNystatin (Topical)NystatinOlanzapine (Zyprexa)Olopatadine Hydrochloride (Patanol)OmeprazoleOnfiOnglyzaOrtho EvraOseltamivir Phosphate (Tamiflu)OTC AlergyOTC Cold medOTC diet pillsOTC VitaminsOxazepamOxcarbazepine (Trileptal)OxectaOxybutyninOxycodoneOxyContinOzempicOzempicPantoprazoleParcopaParoxetinePaxil CRPenicillin VKPercocetPhenazopyridinePhenelzinePhenobarbitalPhentermine (no adverse effects)Phenytec-PhenytoinPhenytecPhenytoin Sodium (Dilantin)PhenytoinPioglitazone Hydrochloride (Actos)PiroxicamPolyethylene Glycol (Glycolax)Potassium ChloridePradaxa (dabigatran)PravacholPravastatinPrednisolonePrednisonePrilosecPromethazine DMPromethazine/CodeinePromethazinePrometriumPropranololProtonixProtriptylineProvigil (modafinil)ProzacQuetiapine Fumarate (Seroquel)QuinaprilQuinineRaloxifene Hydrochloride (Evista)Ramipril (Altace)RanitidineRemeron (mirtazapine) - taken QHSRequip (Ropinirole)RestorilRisedronate Sodium (Actonel)RisperdalRitalinRosiglitazone Maleate (Avandia)RosuvastatinRoxicodoneRyzoltSelegilineSeraxSertraline (Zoloft)Simvastatin (Zocor)SinemetSonata (zaleplon) - taken QHSSpirivaSpironolactoneStatinStratteraSuboxone (buprenorphine)SudafedSumatriptan Succinate (Imitrex)SymbicortSynthroidTamoxifenTamsulosin (Flomax)TanzeumTemazepamTerazosinTervinafine Hydrochloride (Lamisil)TetracyclineTizanidineTobradexTolterodine Tartrate (Detrol LA)TopamaxToujeo InsulinTradjentaTramadolTranxene SDTranxeneTranylcypromineTrazodoneTresiba InsulinTriamcinlnoloneTriamcinolone Acetonide (Nasacort AQ)TriazolamTrimethoprim/SulfamethoxazoleTrimipramineTrivora-28TrulicityTylenolUloricUltracetUltramValium (Diazepam)ValiumValsartan (Diovan)ValtrexVenlafaxine (Effexor)Verapamil SRViagraVicodinVicoprofenVictozaVigamoxVistarilVivitrol (naltrexone)VytorinWarfarin (Coumadin)WarfarinXanax XRXanaxXarelto (rivaroxaban)YasminZelnormZestoreticZolpidem Tartrate (Ambien)ZolpidemZolpimistZyrtec-DCustom (other) Please select from this list of medications: Dosage Units of Measure UnitsmgmcggmLmL/hrtablet(s)capsule(s)drop(s)Custom / Other Units of Measure Frequency Freq.daily2x daily3x daily4x dailyevery 30 minevery hourevery 2 hoursevery 4 hoursevery 8 hoursCustom / Other Frequency Medication Statement plus minus Health History Do you have or have you ever had: Hx1 1. Head / brain injuries or illnesses (e.g. concussion) YesNoNot Sure 1. Checkboxes TBI / Concussion Brain Tumor Parkinson's Alzheimer's Encephalitis Autism Meningitis How severe was your TBI / Concussion? * Severe TBI: A penetrating injury to the brain or loss of consciousness for 24+ hours Moderate TBI: Loss or alteration of consciousness for 1 hour and < 24 hours Mild TBI: Loss or alteration of consciousness for < 1 hour 1. Explain * 2. Seizures / epilepsy YesNoNot Sure How many instances? * Single Seizure Multiple Seizures (Epilepsy) Are you taking anti-seizure medication? * I take anti-seizure medication I do not take anti-seizure medication How long has it been since your last seizure? * < 4 years 4 years 5 - 10 years > 10 years 2. Explain * 3. Eye problems (except glasses or contacts) YesNoNot Sure 3. Checkboxes Glaucoma Cataracts Color Blindness Monovision Presbyopia Macular Degeneration Strabismus Retinal Detachment 3. Explain * 4. Ear and / or hearing problems YesNoNot Sure 4. Checkboxes Vertigo Tinnitus Ear Infections Perforated Eardrum Cholesteatoma Labrynthitis Hearing Loss Otosclerosis 4. Explain * 5. Heart disease, heart attack, bypass, or other heart problems YesNoNot Sure 5. Checkboxes Irregular Heartbeat Chest Pain Heart Attack Bypass Cardiomyopathy Congestive Heart Failure Congenital Heart Disease Heart Valve Condition What type of Irregular Heartbeat? A-Fib (Atrial Fibrillation) Supraventricular Arrhythmia General / Not Sure What type of Heart Valve Condition? Aortic Regurgitation Aortic Stenosis Mitral Regurgitation Mitral Stenosis 5. Explain * 6. Pacemaker, stents, implantable devices, or other heart procedures YesNoNot Sure 6. Checkboxes Pacemaker Defibrillator Stents Valve Repair Heart Ablation Heart Transplant 6. Explain * 7. High blood pressure YesNoNot Sure Do you currently manage hypertension with medication? Yes No 7. Explain * 8. High cholesterol YesNoNot Sure Do you currently manage cholesterol with medication? Yes No 8. Explain * 9. Chronic (long-term) cough, shortness of breath, or other breathing problems YesNoNot Sure 9. Checkboxes Chronic Cough Shortness of Breath Chest Tightness Wheezing Difficulty Breathing Pneumothorax 9. Explain * 10. Lung disease (e.g., asthma) YesNoNot Sure 10. Checkboxes Asthma Tuberculosis COPD Emphysema Chronic Bronchitis Cystic Fibrosis 10. Explain * 11. Kidney problems, kidney stones, or pain / problems with urination YesNoNot Sure 11. Checkboxes Kidney Infection Polycystic Kidney Disease Hematuria Dialysis Kidney Stones Painful Urination Glomerular Disease 11. Explain * 12. Stomach, liver, or digestive problems YesNoNot Sure 12. Checkboxes GERD Ulcerative Colitis Dysphasia Diverticulitis Constipation Hemorrhoids Gallstones Gastritis Bowel Obstruction IBS Celiac Disease Pancreatitis Crohn's Disease 12. Explain * 13. Diabetes or blood sugar problems YesNoNot Sure 13b. Insulin used? YesNoNot Sure 14. Anxiety, depression, nervousness, other mental health problems YesNoNot Sure 14. Checkboxes ADHD Bipolar Depression Anxiety PTSD Schizophrenia Dementia 14. Explain * 15. Fainting or passing out YesNoNot Sure 15. Explain * 16. Dizziness, headaches, numbness, tingling, or memory loss YesNoNot Sure 16. Checkboxes Dizziness Headaches Migraines Numbness Tingling Memory Loss Hx2 16. Explain * 17. Unexplained weight loss YesNoNot Sure 17. Explain * 18. Stroke, mini-stroke (TIA), paralysis, or weakness YesNoNot Sure 18. Checkboxes Stroke Mini-Stroke (TIA) Paralysis Weakness 18. Explain * 19. Missing or limited use of arm, hand, finger, leg, foot, toe YesNoNot Sure 19. Checkboxes Amputation Missing Limb Impaired Limb Have you completed a skill performance evaluation (SPE) before? Yes No 19. Explain * 20. Neck or back problems YesNoNot Sure 20. Checkboxes Disc Herniation Scoliosis Spinal Stenosis Spondylosis Spinal Tumor Degenerative Disc Disease Chronic Pain Ankylosing Spondylitis 20. Explain * 21. Bone, muscle, joint, or nerve problems YesNoNot Sure 21. Checkboxes ALS Myasthenia Gravis Guillan Barre Peripheral Neuropathy Charcot-Marie-Tooth Disease Sciatica Arthritis Osteoporosis Osteopenia Multiple Sclerosis 21. Explain * 22. Blood clots or bleeding problems YesNoNot Sure 22. Checkboxes DVT Pulmonary Embolism Blood Clot Bleeding Problem Anemia/Sickle Cell Hemophilia Factor V Leiden Deficiency Abdominal Aortic Aneurysm (AAA) Thoracic Aortic Aneurysm (TAA) Aneurysm (non-specific) 22. Explain * 23. Cancer YesNoNot Sure 23. Explain * 24. Chronic (long-term) infection or other chronic diseases YesNoNot Sure 24. Checkboxes Lyme Disease Epstein Barr Virus Ebola Enterovirus AIDS Hepatitis Rheumatoid Arthritis MRSA 24. Explain * 25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring YesNoNot Sure 25. Checkboxes Pauses in Breathing while Asleep Daytime Sleepiness Loud Snoring Narcolepsy Sleep Apnea 25. Explain * 26. Have you ever had a sleep test (e.g., sleep apnea)? YesNoNot Sure 26. Explain * 27. Have you ever spent a night in the hospital? YesNoNot Sure 27. Explain * 28. Have you ever had a broken bone? YesNoNot Sure 28. Explain * 29. Have you ever used or do you now use tobacco? YesNoNot Sure 30. Do you currently drink alcohol? YesNoNot Sure 31. Have you used an illegal substance within the past two years? YesNoNot Sure 31. Explain * 32. Have you ever failed a drug test or been dependent on an illegal substance? YesNoNot Sure 32. Explain * Applicable Clearance Letters: Addressing these beforehand will help reduce the risk of an incomplete exam and ensure a more timely re/certification. Paragraph Captcha Save / Go to Dashboard If you are human, leave this field blank.