To fill out Form MCSA-5875, complete Section 1 yourself — identification, health history, and medications — then sign and date it before the certified medical examiner begins the clinical portion. The examiner fills in every other part of the form based on the physical exam. Your job is to be accurate and complete on Section 1; getting that right is what makes the rest of the visit go smoothly.
Before You Sit Down With the Form
You can download and print Form MCSA-5875 from the FMCSA website and pre-fill Section 1 at home.1Federal Motor Carrier Safety Administration. Medical Examination Report Form MCSA-5875 Most examiners keep blank copies on hand, but doing it in advance lets you check your answers against your own records rather than working from memory in a waiting room.
Bring these to the appointment:
- Your valid driver’s license. The examiner needs your license number and issuing state, and the name on the form must match the license exactly.
- A complete medication list with dosages: prescriptions, over-the-counter drugs, herbal remedies, and supplements.
- Corrective lenses or hearing aids if you use them while driving.
- Recent notes or clearance letters from any specialists you see — cardiologist, neurologist, endocrinologist, sleep medicine.
- At least 90 days of CPAP usage data if you’ve been diagnosed with sleep apnea.
- A blood sugar log and your most recent hemoglobin A1C if you’re diabetic.
The examiner must be listed on the FMCSA’s National Registry of Certified Medical Examiners. Your regular doctor cannot perform this exam unless they hold that certification.2Federal Motor Carrier Safety Administration. National Registry of Certified Medical Examiners
Section 1: Identification
Section 1 opens with basic identification: full legal name, date of birth, address, phone number, and driver’s license number with issuing state.3Federal Motor Carrier Safety Administration. Medical Examination Report Form MCSA-5875 Match your license exactly. A misspelled name or a wrong license number can cause problems when the examiner uploads your results to the National Registry.
Section 1: Health History Checklist
Most of Section 1 is a yes/no checklist covering conditions you’ve ever had or currently have. It includes heart disease, seizures, hearing loss, diabetes, breathing problems, kidney disease, nervous or psychiatric disorders, and many others.3Federal Motor Carrier Safety Administration. Medical Examination Report Form MCSA-5875 A “yes” answer does not automatically disqualify you. It tells the examiner where to look more closely during the physical.
The form also asks about prior surgeries, hospitalizations, and any history of failed DOT physicals. Be thorough. Leaving something out because it seems minor can backfire: the examiner may find it during the clinical exam anyway, and the inconsistency between what you wrote and what shows up raises a red flag.
For any “yes” answer, be ready to explain — when it happened, whether treatment is ongoing, what medications are involved, and which clinician manages the condition. Specialist notes and clearance letters do their real work here, backing up what you’ve written on the form.
Section 1: Medications
List every medication you take. Include the dosage and the condition it treats. The examiner uses this list to evaluate whether any drug could impair your ability to drive safely.
Some medications are automatically disqualifying: Schedule I controlled substances, anti-seizure medications used to prevent seizures, and methadone. Amphetamines, narcotics, and other habit-forming drugs also disqualify you unless a licensed prescriber certifies in writing that the medication is safe for you to use while driving. Even with that letter, the examiner has the final say and can still find you unqualified.4Federal Motor Carrier Safety Administration. What Medications Disqualify a CMV Driver?
If any of your medications fall into the categories above, bring the prescriber’s letter with you. Writing the drug on the form without the supporting documentation puts the examiner in the position of having to disqualify by default.
Signing and Certifying
Once your health history and medication list are complete, you sign and date Section 1 to certify that everything you reported is truthful. The examiner will not begin the clinical exam until you’ve signed.
The signature carries legal weight. Deliberate omissions or false statements can invalidate the exam and any medical certificate issued from it.5Federal Motor Carrier Safety Administration. What Happens If a Driver Is Not Truthful About His/Her Health History on the Medical Examination Form Civil penalties under federal law can reach up to $10,000 per violation for knowingly falsifying information on a required record.6Office of the Law Revision Counsel. 49 USC 521 – Civil Penalties Visiting a different examiner later and leaving out unfavorable history is treated the same way, and can result in permanent disqualification.
Supplemental Forms You May Need to Bring
Two situations require paperwork that goes with Form MCSA-5875 rather than being part of it.
Insulin-Treated Diabetes
If you use insulin, your treating clinician must complete Form MCSA-5870, the Insulin-Treated Diabetes Mellitus Assessment Form, before your DOT physical. The clinician attests that your insulin regimen is stable and your diabetes is properly controlled. You have 45 days from the clinician’s signature to provide this form to the certified medical examiner.7Federal Motor Carrier Safety Administration. Insulin-Treated Diabetes Mellitus Assessment Form, MCSA-5870 If it’s older than that on the day of your exam, the examiner won’t accept it and you’ll need a new one.
Missing or Impaired Limb
Drivers with a missing or impaired limb who want to operate in interstate commerce apply separately for a Skill Performance Evaluation (SPE) certificate. The SPE requires you to demonstrate safe operation of a CMV through on-road and off-road driving activities, and if you use a prosthetic device you must be wearing it during the evaluation.8Federal Motor Carrier Safety Administration. Skill Performance Evaluation Certificate Program The SPE is its own process, not something entered on Form MCSA-5875.
What the Examiner Fills In (Not Your Job)
After you sign Section 1, the examiner completes the rest of the form. That includes your height, weight, pulse, blood pressure, vision and hearing test results, urinalysis findings, and a systematic check of your cardiovascular, respiratory, musculoskeletal, and neurological systems.3Federal Motor Carrier Safety Administration. Medical Examination Report Form MCSA-5875 The urinalysis on Form MCSA-5875 checks for protein, blood, glucose, and specific gravity. It is not a drug test; drug and alcohol testing is a separate program.
The examiner records the final determination — physically qualified, temporarily disqualified, or does not meet standards — on the form itself.
What You Walk Out With
You typically don’t receive a copy of the completed Form MCSA-5875. The examiner keeps the original on file for at least three years from the date of the exam.9eCFR. 49 CFR 391.43 – Medical Examination; Certificate of Physical Examination
If you pass, the examiner issues Form MCSA-5876, the Medical Examiner’s Certificate. That is the document you carry while driving and provide to your employer.10Federal Motor Carrier Safety Administration. Medical Examiner’s Certificate (MEC), Form MCSA-5876 The examiner also uploads your exam results to the FMCSA National Registry by midnight local time of the next calendar day after the exam. For CDL and commercial learner’s permit holders, the results are transmitted electronically to your State Driver Licensing Agency so your driving record reflects your current medical status.2Federal Motor Carrier Safety Administration. National Registry of Certified Medical Examiners
Keep Form MCSA-5876 with you when driving, and give a copy to your carrier. That certificate is your proof that Form MCSA-5875 was completed and that you’re medically qualified.