DS-6572 Driver Medical Eval for LES

U.S. Department of State

Bureau of Medical Services

OMB APPROVAL NO 1405-XXXX
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: XX MINUTES

DRIVER MEDICAL EVALUATION QUESTIONNAIRE
Section I: Demographic and Employment Information
Driver Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Locally Employed Staff

Employment Category:

USDH

Job Title/Section

Other:
Post

Type of Evaluation:

Type of Evaluation:

Initial

Full-Time/Higher Risk Vehicle Driver (every 2 years)

Periodic

Chauffeur

Truck (over 25K lbs)

Follow-Up

Hazmat Transport

Van/Bus (15+ passengers)

Incidental Driver (every 4 years)

Section II: Health History
MEDICAL EVALUATION
Do you have any medical
restrictions related to
driving? i.e., have you ever
been told by a health
professional to avoid driving
for any reason?
Yes
No

If "Yes", describe below

If "Yes", describe below
Do you have any medical
restrictions related to
performing certain job duties
(i.e., have you ever been
told by a health professional
to avoid doing certain job
tasks including lifting,
standing for extended
periods of time, bending,
stooping, etc.)?
Yes

No

Are you under the care of a
medical provider for any
medical or mental health
conditions?
Yes

No

Do you have any additional
medical/mental health
condition(s) for which you
are not currently being
treated or seen by a health
professional?
Yes

If "Yes", describe below

If "Yes", describe below

No

MEDICAL CONDITIONS
(Are you under the care of a medical provider for any of the following medical conditions (select “yes” or “no”))
Sleep apnea, narcolepsy, or conditions that lead to drowsiness
Have you been diagnosed with sleep apnea, narcolepsy, or any condition that may cause daytime drowsiness or problems staying awake?
Yes

No

Diabetes, blood glucose abnormalities
Have you been diagnosed
with diabetes or abnormal
blood glucose?
Yes
DS-6572
04-2024

No

How are you treated?
Insulin-treated

Non-insulin treated (oral or injectable meds)

No current insulin or meds
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DOB

Epilepsy, seizures, or conditions that lead to loss of consciousness
Have you been diagnosed
with epilepsy, or have you
ever had one or more
seizures/episodes of loss of
consciousness?
Yes
No

If "Yes", describe below

Other
List any additional medical or mental health condition(s) for which you are currently being treated.

MEDICATION
I currently do not take any prescribed, over the counter, controlled, or other medications or supplements.
(If initialed, move directly to VISION)

(Initials)
List any current
medications/drugs taken
either on a routine schedule
or as needed.
Include all prescribed
medications,
over-the-counter
medications, controlled
substances, and/or
supplements.

Medication

Dose

How Often (once a day, as
needed, etc.)

When Started
(mm-yyyy)

Comments or Additional
Information

VISION
Yes

No

Have you ever been told by a health professional that you have a visual impairment?

Yes

No

Do you wear glasses or contact lenses?

Yes

No

Have you ever had procedures to correct your vision?

Yes

No

Have you ever been told by a health professional that you have other problems related to your vision or eyes (e.g., monocular
vision, colorblindness, etc.)?

IF YES:

Yes

No

Do you wear them while driving?

HEARING
Yes

No

Have you ever been told by a health professional that you have hearing loss?

Yes

No

Do you currently wear (or have you ever worn) hearing aids?

Section III: Physical Exam
Part I: Blood Pressure
STANDARD: Needs to be . 155/95. If above 155/95, see flow chart.
INSTRUCTIONS: If first reading is over 155/95, wait 15 min between readings; ensure proper cuff size; both feet on the floor, arm resting on table.
Perform second BP, if needed. Report systolic and diastolic as numerical values. First Reading Second Reading (if needed). Report systolic and
diastolic as numerical values.
First Reading
Systolic:
DS-6572

Diastolic:

Second Reading
Systolic:

Diastolic:
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DOB

Part II: Vision
STANDARD: At least 20/40 acuity (Snellen) required in each eye with, or without, correction. The horizontal field of vision must be 70 degrees with
each eye, 140 degrees overall.
INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording the distance
vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet (6.096 meters)
as denominator. If the individual wears corrective lenses, these should be worn while visual acuity is being tested. If the driver
habitually wears contact lenses, or needs to do so while driving, employee must provide sufficient evidence of good tolerance and
adaption to their use.

NUMERICAL READINGS MUST BE PROVIDED
ACUITY

UNCORRECTED

CORRECTED

HORIZONTAL
FIELD OF VISION

Right Eye

20/

20/

20/

Left Eye

20/

20/

20/

Both Eyes

20/

20/

20/

Individual recognizes and distinguishes all lights on traffic control
signals and devices showing standard red/green colors.*
Yes

No

*see Color Vision Instructions document

Part III: Hearing
STANDARD: 1. Must first perceive forced whisper voice > 5 feet (1.5 meters) with or without a hearing aid. 2. If needed, audiometric testing can be
performed and average hearing loss (at 500Hz, 1000Hz, 2000Hz) should be 40dB in better ear.
INSTRUCTIONS: Always perform the whisper test first. If individual passes, the hearing section is complete. ONLY perform audiometric testing if
needed. To calculate the average for the Hz values, add the readings for the frequencies and divide by three.
NUMERICAL READINGS MUST BE PROVIDED
Record distance from individual at which forced whispered voice can first be heard.
Right Ear

Left Ear

500 Hz
Pass
Fail

Per

ft

m Per

ft

m

If FAIL, perform
audiometric testing
(record hearing loss
in dB)

1000 Hz

2000 Hz

Average

Right Ear
LeftEar

Part IV: Tuberculosis Risk Assessment
STANDARD: All drivers require a risk assessment and should have a chest x-ray (if high or moderate risk) and other testing (if low risk) as required. All
employees MUST complete the TB Risk Assessment Questionnaire and clinician must attach to this DME Questionnaire as a supplemental form.

Part V: Urinalysis
STANDARD: OPTIONAL, based on results of history in Section II.
NUMERICAL READINGS MUST BE PROVIDED
Urine Speciman

SP. GR.

Protein

Blood

Sugar

Part VI: Review of Symptoms
GENERAL

VISION/EYES

HEARING

CARDIOVASCULAR

RESPIRATORY

Fever

Pain

Tinnitus

Chest Pain

Shortness of breath

Chills

Redness

Hearing Change

Palpitations

Cough

Dizziness

Vision Change

Pain with breath

Weakness
ENDOCRINE

Hemoptysis
MENTAL HEALTH

MUSCULOSKELETAL

NEUROLOGICAL

Flushing

Irritability

Joint Pain

Headache

Skin Changes

Anxiety

Back Pain

Numbness

Temperature Instability

Depression

Neck Pain

Tingling

Swelling

Mood Changes

Weakness

OTHER

None

If any boxes are checked (except "None"), please describe below.

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Name of Examinee

DOB

Part VII: Clinical Evaluation
Normal?

Abnormal?

If abnormal, provide details.

General (alert/oriented, general
mental status)
Cardiovascular/Heart
Respiratory System
Musculoskeletal
Other
Other

Part VIII: Additional Forms
If the individual has history of sleep disorder, diabetes, seizures, visual impairment or hearing impairment, please follow the supplemental procedures.
Diabetes
Seizures/Epilepsy
Check boxes for each additional form that needs to be completed (listed in toolkit)

Vision (monocular. etc.)
Other, follow-up as recommended (sleep
disorder, cardivascular, etc.)

Section IV: Local or HU Medical Provider/Clinician Recommendation
Based on my examination/evaluation, performed on
Full driving for (select one):

2 years (max for full-time)

(mm-dd-yyyy), I recommend:
4 years (max for incidental)

With corrective lenses (check, if applicable)
With hearing aids (check, if applicable)
Driving permitted only for

(length of time in months), due to

Recommend re-evaluation once

(diagnosis).
(employee name) has been effectively managed for a duration of

(months/years) and/or stability of condition has been documented by treating provider.
No driving permitted for

(length of time in months) due to

Recommend re-evaluation once

(diagnosis).
(employee name) has been effectively managed for a duration of

(months/years) and/or stability of condition has been documented by treating provider.
The individual is not permitted to drive.
More information needed:
Name of Provider/Clinician

Signature of Provider/Clinician

Clinic Address/Post

Phone Number

DS-6572

Medical Credential/Specialty

Email

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Name of Examinee

DOB

Section V: HU Medical Provider/Clinician Recommendation
(REQUIRED, if the above is completed by a local provider)
If the evaluation was performed by a local provider, indicate if your recommendation below:
Concur with recommendation above
Modify recommendation as follows:
More information needed:
Name of Provider/Clinician

Signature of Provider/Clinician

Clinic Address/Post

Phone Number

Medical Credential/Specialty

Email

Paperwork Reduction Act Statement
Releases or disclosures of confidential medical information are governed by the Privacy Act of 1974, as amended, 5 U.S.C. § 552a et seq., and the
Rehabilitation Act of 1973, as amended, 29 U.S.C. § 701 et seq.
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to 5 CFR 930.108, 339.301 and the Foreign Service Act of 1980, as amended (Title 22 U.S.C.
4084, 3901, and 3984).
PURPOSE: The information requested on this form will be used to determine medical eligibility for issuance of a driver medical certificate.
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
The information may also be made available to local Health Units. More information on the Routine Uses for the system can be found in the System of
Records Notice State-24, Medical Records
DISCLOSURE: Providing this information is voluntary; however, failure to provide this information may result in denial of a driver medical certification.
The Genetic Information Nondiscrimination Act of 2008 (GINA)
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008
(GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you NOT provide any genetic
information when responding to this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical
history, the results of an individual's or family members' genetic tests, the fact that an individual or an individual's family member sought or received
genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual
or family member receiving assistive reproductive services.
DS-6572

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