department of transportation ( physical examination...

Department of Transportation (DOT)Physical Examination ChecklistPLEASE READ THE CHECKLIST BELOW BEFORE ARRIVING SO YOU MAY HAVE A SUCCESSFUL VISIT.

BEFORE YOUR VISIT, PLEASE MAKE SURE YOU:

❏ Bring your glasses and wear any contacts or hearing aidsif you normally do.

❏ Bring a current list of all your medications including overthe counter medications.

❏ If you have diabetes, bring a copy of your HbA1C bloodtest for our records.

❏ We will perform a urine test to check for sugar in yoururine. If you have sugar in your urine, you will be requiredto get a clearance letter from your physician and copy ofrecent HbA1C results.

❏ Insulin requires special paper work, let us know in advance.

❏ If your blood pressure is 140/90 or more, you will need aclearance letter from your doctor. Please, remember to takeany medication as you normally would take them prior toyour appointment. Avoid coffee, nicotine and energy drinksprior to your appointment.

❏ If you have had a heart attack, heart problems or Stroke,please bring a clearance letter from your cardiologist orneurologist. There may be a minimum waiting period to geta card. You should bring records of any testing you have hadfor example cardiac stress tests, ECHO or CT/MRI scans.

❏ If you are taking blood thinners that require regularmonitoring with an INR lab, bring your most recent 3INR results and a clearance letter with the reason as towhy you are taking this medication.

❏ If you are overweight or obese, and have a BMI of 33 ormore, you will be screened by a provider for the risk ofobstructive sleep apnea. You may be required to have asleep study if you are found to be at high risk.

❏ If you have newly been diagnosed with sleep apnea youwill need a compliance report with at least 30 days ofCPAP compliance. Per DOT requirements, you must useyour CPAP > 4 hours each night 70% of the time.

❏ If you have known sleep apnea, you will need acompliance report with at least 90 days of CPAPcompliance. Per DOT requirements, you must useyour CPAP > 4 hours each night 70% of the time.

❏ If you take any DEA controlled medication you will needa form from us to take to your doctor to sign, let us knowin advance and we will give you a copy.

❏ You will also need clearance letters for mental healthdiagnoses and medications.

❏ If you have had surgery/an illness/hospital admission/ERvisit/or this is a return to work DOT exam, please bring aclearance letter from your treating provider.

❏ This list is NOT exhaustive. You may be asked forsomething else depending on your medical evaluation.Please bring any office visits notes from your doctor itwill always be helpful.

Every DOT card needs a physical form to go with it, if you are given a limited duration card, you will need a new physical when that card expires.

Questions/concerns? PLEASE call our office with any questions BEFORE your appointment date. We recommend you schedule an appointment well in advance of your current DOT card expiration.

Performance Occupational Health

1801 Maplewood Dr . Sulphur, La 70663

P.337-888-3163 F.337-888-3164

Email. admin@performanceoccupationalhealth.com