Page 1 of 2Disponible en franais5080E (2015/10) Queen's Printer for Ontario, 2015

FMCSA

Ministry of Transportation

FMCSA Medical Report

Complete this form if you are requesting proof of medical fitness to comply with the Federal Motor Carrier Safety Administration (FMCSA) requirement.

The ministry requires you to have this form completed by a physician or nurse practitioner who has knowledge of your medical condition. Completion of this form may require that your physician or nurse practitioner conduct a medical assessment or use recent information on your medical file that has been obtained within the last 3 months. To avoid delays in reviewing your form all questions must be completed in full. For additional information, please visit www.mto.gov.on.ca/english/safety/medical-review.shtml.

Fax completed medical report to: 416 235-3400 or 1 800 304-7889. Clearly indicate on the fax cover sheet the following, This request is for a Medical Confirmation Letter for a G class or D class licence holder operating in the United States. You are encouraged to keep a copy of the medical report and fax confirmation for your own records.

Information in this form is collected under the authority of the Highway Traffic Act, s. 15, Reg. 340/94, and is used to evaluate fitness to operate a motor vehicle. Direct enquiries to: Ministry of Transportation, Driver Improvement Office, Medical Review Section, 77 Wellesley St. W Box 589, Toronto ON M7A 1N3. Phone: 416 235-1773 or 1 800 268-1481.

Fields marked with an asterisk (*) are mandatory.

Driver InformationDrivers Licence Number* Date of Birth (yyyy/mm/dd)

Last Name First Name Middle Initial

Mailing AddressUnit Number Street Number Street Name PO Box

City/Town Province Postal Code

Driver's Certificate and Release of InformationI certify that the foregoing information is to the best of my knowledge correct and agree to this report and any future report from this examination only being given to the Ministry of Transportation.

The cost of any examination and for the completion of this form by your physician or other health care provider is not a benefit of OHIP and not the responsibility of the Ministry of Transportation and must be paid for by the applicant.Business Telephone Number Home Telephone Number Signature Date (yyyy/mm/dd)

Complete Health HistoryTo be completed in full by examining physician or specialist or Nurse Practitioner. Yes answers should be explained on the reverse side under History Details.

1. Diseases of Senses (deafness, vertigo, visual deficiencies, etc.) Yes No

2. Cardiovascular Diseases (heart failure, angina, infarction, embolism, arrhythmia, syncope, surgery, etc.) Yes No

3. Respiratory Diseases (asthma, chronic bronchitis, emphysema, chronic obstructive pulmonary disease, etc.) Yes No

4. Diseases of the Musculo-Skeletal System (Fracture(s) or Amputation, Arthritis, etc.) Yes No

5. Metabolic Diseases (Diabetes (+) (-), Hypoglycemia, Thyroid, etc.) Yes No

6. Psychiatric Disorders (Psychoneurosis, Psychosis, etc.) Yes No

7. Addictions (Alcohol, Sedatives, Tranquillizers, Narcotics, etc.) Yes No

8. Other Diseases (Blackouts, Fainting Spells, Anemia, Cancer, Sleep Disorders, etc.) Yes No

9. Neurological Diseases (Seizures, Cerebrovascular Diseases, Parkinson's Disease, Multiple Sclerosis, Dementia, Head Injury, etc.) Yes No

Date of Most Recent Seizure (yyyy/mm/dd) Date of Examination (yyyy/mm/dd)

www.mto.gov.on.ca/english/safety/medical-review.shtmlwww.mto.gov.on.ca/english/safety/medical-review.shtml

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FMCSA

History Details1. EyesEye Acuity without corrective lenses Acuity with corrective lenses Horizontal Field of Vision

Right 20/ 20/ Normal Restricted

Left 20/ 20/ Normal Restricted

Both eyes together 20/ 20/ Normal Restricted

2. HearingClass B, C, E, F Highway Traffic Act standard; Hearing loss in better ear with/without hearing aid, no greater than 40 decibels at 500, 1,000 and 2,000 hertz. Class A, D must meet if operating in U.S; Hearing loss in better ear with/without hearing aid, no greater than 40 decibels averaged at 500, 1,000 and 2,000 hertz

Does hearing meet standards? Yes No Are hearing aids required? Yes No

3. HeartApical Rate Murmurs Rhythm Blood Pressure

4. LocomotorUpper Extremity Lower Extremity Neck and Lumbar

5. Chest/Abdomen

6. UrinaryUrine Protein Glucose

7. Diabetes Yes NoType Treatment Diet alone Oral medication - amt per 24hrs.

Insulin - amt per 24 hrs.

8. HypoglycemiaHas the patient had a reported episode of severe hypoglycemia requiring outside intervention in the past 6 months? Yes NoLoss of Consciousness? Decrease in cognition, etc.

9. NeurologicalGait and Stance Reflexes Tremor Coordination

10. Evidence of Emotional Disorder Instability Yes No Neurosis Yes No Psychosis Yes No

11. Addictions. If yes to Q7 on reverse please specifyPeriod of Abstinence Alcoholism Drug Habituation

< 6 months6 to < 12 months 12 months

History Details and Summary (additional comments or information to take into consideration e.g. diagnosis, prognosis, treatment, date condition resolved, etc.)

Physician's SignatureFamily Physician and/or Treating Physician Nurse Practitioner Specialist (Specify)

How long has this person been your patient?

Physician/Nurse Practitioner's NameLast Name First Name Middle Initial

AddressUnit Number Street Number Street Name PO Box

City/Town Province Postal Code

Signature Date (yyyy/mm/dd)

FMCSA Medical Report Driver InformationDriver's Certificate and Release of InformationComplete Health History

History Details1. Eyes2. Hearing3. Heart4. Locomotor5. Chest/Abdomen6. Urinary7. Diabetes8. Hypoglycemia9. Neurological10. Evidence of Emotional Disorder11. Addictions. If yes to Q7 on reverse please specify

Physician's Signature

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FMCSA

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FMCSA Medical Report

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Government of Ontario

Ministry of

Transportation

FMCSA Medical Report

Complete this form if you are requesting proof of medical fitness to comply with the Federal Motor Carrier Safety Administration (FMCSA) requirement.

The ministry requires you to have this form completed by a physician or nurse practitioner who has knowledge of your medical condition. Completion of this form may require that your physician or nurse practitioner conduct a medical assessment or use recent information on your medical file that has been obtained within the last 3 months.

To avoid delays in reviewing your form all questions must be completed in full. For additional information, please visitwww.mto.gov.on.ca/english/safety/medical-review.shtml.

Fax completed medical report to: 416 235-3400 or 1 800 304-7889. Clearly indicate on the fax cover sheet the following,This request is for a Medical Confirmation Letter for a G class or D class licence holder operating in the United States. You are encouraged to keep a copy of the medical report and fax confirmation for your own records.

Information in this form is collected under the authority of theHighway Traffic Act, s. 15, Reg. 340/94, and is used to evaluate fitness to operate a motor vehicle. Direct enquiries to: Ministry of Transportation, Driver Improvement Office, Medical Review Section, 77 Wellesley St. W Box 589, Toronto ON M7A 1N3. Phone: 416 235-1773 or 1 800 268-1481.

Fields marked with an asterisk (*) are mandatory.

Driver Information

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Driver Information

Mailing Address

Driver's Certificate and Release of Information

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Driver's Certificate and Release of Information

I certify that the foregoing information is to the best of my knowledge correct and agree to this report and any future report from this examination only being given to the Ministry of Transportation.

The cost of any examination and for the completion of this form by your physician or other health care provider is not a benefit of OHIP and not the responsibility of the Ministry of Transportation and must be paid for by the applicant.

Complete Health History

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Complete Health History

To be completed in full by examining physician or specialist or Nurse Practitioner.Yes answers should be explained on the reverse side under History Details.

1. Diseases of Senses (deafness, vertigo, visual deficiencies, etc.)

2. Cardiovascular Diseases (heart failure, angina, infarction, embolism, arrhythmia, syncope, surgery, etc.)

3. Respiratory Diseases (asthma, chronic bronchitis, emphysema, chronic obstructive pulmonary disease, etc.)

4. Diseases of the Musculo-Skeletal System (Fracture(s) or Amputation, Arthritis, etc.)

5. Metabolic Diseases (Diabetes (+) (-), Hypoglycemia, Thyroid, etc.)

6. Psychiatric Disorders (Psychoneurosis, Psychosis, etc.)

7. Addictions (Alcohol, Sedatives, Tranquillizers, Narcotics, etc.)

8. Other Diseases (Blackouts, Fainting Spells, Anemia, Cancer, Sleep Disorders, etc.)

9. Neurological Diseases (Seizures, Cerebrovascular Diseases, Parkinson's Disease, Multiple Sclerosis, Dementia,

Head Injury, etc.)

History Details

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History Details

1. Eyes

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1. Eyes

Eye

Acuity without corrective lenses

Acuity with corrective lenses

Horizontal Field of Vision

Right

Left

Both eyes together

2. Hearing

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2. Hearing

Class B, C, E, FHighway Traffic Act standard; Hearing loss in better ear with/without hearing aid, no greater than 40 decibels at 500, 1,000 and 2,000 hertz.Class A, D must meet if operating in U.S; Hearing loss in better ear with/without hearing aid, no greater than 40 decibels averaged at 500, 1,000 and 2,000 hertz

Does hearing meet standards?

Are hearing aids required?

3. Heart

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3. Heart

4. Locomotor

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4. Locomotor

5. Chest/Abdomen

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5. Chest/Abdomen

6. Urinary

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6. Urinary

7. Diabetes

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7. Diabetes

Treatment

8. Hypoglycemia

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8. Hypoglycemia

Has the patient had a reported episode of severe hypoglycemia requiring outside intervention in the past 6 months?

9. Neurological

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9. Neurological

10. Evidence of Emotional Disorder

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10. Evidence of Emotional Disorder

Instability

Neurosis

Psychosis

11. Addictions. If yes to Q7 on reverse please specify

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11. Addictions. If yes to Q7 on reverse please specify

Period of Abstinence

Alcoholism

Drug Habituation

< 6 months

6 to < 12 months

12 months

Physician's Signature

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Physician's Signature

Physician/Nurse Practitioner's Name

Address

11.0.0.20130303.1.892433.887364

MTO

FMCSA Medical Report

MTO

FMCSA Medical Report

CurrentPageNumber: NumberofPages: Print Form: TextField1: Driver Information. Drivers Licence Number. This field is mandatory.: Driver Information. Date of Birth. : Physician's Signature. Physician/Nurse Practitioner's Name. Last Name: Physician's Signature. Physician/Nurse Practitioner's Name. First Name: Physician's Signature. Physician/Nurse Practitioner's Name. Middle Initial: Physician's Signature. Address. Unit Number: Physician's Signature. Address. Street Number: Physician's Signature. Address. Street Name: Physician's Signature. Address. Post Office Box: Physician's Signature. Address. City or Town: Physician's Signature. Address. Province: Physician's Signature. Address. Postal Code. : Driver's Certificate and Release of Information. Business Telephone Number: Driver's Certificate and Release of Information. Home Telephone Number: Physician's Signature. Signature: Physician's Signature. Date. : 10. Evidence of Emotional Disorder. Psychosis. Yes: 10. Evidence of Emotional Disorder. Psychosis. No: 1. Eyes. Both eyes together. Acuity with corrective lenses. 20/: 3. Heart. Apical Rate: 3. Heart. Murmurs: 3. Heart. Rhythm: 3. Heart. Blood Pressure: 4. Locomotor. Upper Extremity: 4. Locomotor. Lower Extremity: 4. Locomotor. Neck and Lumbar: 5. Chest/Abdomen: 6. Urinary. Urine Protein: 6. Urinary. Glucose: 7. Diabetes. Type: 7. Diabetes. Treatment. Diet alone : 07. Diabetes. Treatment. Oral medication - amt per 24hrs.: 07. Diabetes. Treatment. Specify: 7. Diabetes. Treatment. Insulin - amt per 24 hrs.: 0Physician's Signature. How long has this person been your patient?: 8. Hypoglycemia. Decrease in cognition, etc.: 9. Neurological. Gait and Stance: 9. Neurological. Reflexes: 9. Neurological. Tremor: 9. Neurological. Coordination: 11. Addictions. If yes to Q7 on reverse please specify. Period of Abstinence. 12 months. Alcoholism: 011. Addictions. If yes to Q7 on reverse please specify. Period of Abstinence. 12 months. Drug Habituation: 011. Addictions. If yes to Q7 on reverse please specify. History Details and Summary (additional comments or information to take into consideration e.g. diagnosis, prognosis, treatment, date condition resolved, etc.): Physician's Signature. Family Physician and/or Treating Physician: 0Physician's Signature. Nurse Practitioner: 0Physician's Signature. Specialist (Specify): 0Physician's Signature. Specify: