PHYSICAL EXAMINATION REPORT
For S or P Endorsement
Wisconsin Department of Transportation (WisDOT)
MV3030B 8/2015
Ch. 343 Wis. Stats. & Trans. 112 Admin. Code
Medical Review, PO Box 7918, Madison, WI 53707-7918
Telephone: (608) 266-2327 FAX: (608) 267-0518
Email: dmvmedical@dot.wi.gov
Incomplete forms will be returned for completion.
Street Address City State ZIP Code
(Area Code) Telephone Number
Note: Pursuant to Trans 112, Wis. Admin. Rules (copy available upon request); this report is to be completed prior to consideration for licensing. The Secretary of the Department of
Transportation is, by statute, responsible for the decision of driver’s licensing. Any charges or fees for the medical or vision examinations and the preparation or completion of this form are
responsibility of the applicant (driver).
VISION SECTION – REQUIRED
Numerical readings must be provided.
ACUITY UNCORRECTED CORRECTED
Is the temporal field of vision at least 70 degrees from center in each eye?
Right Eye
20/
20/
Can the applicant recognize and distinguish the colors red, amber, and green?
Left Eye
Are corrective lenses required when driving?
Medical License No. (if different from below)
(Examining Authority Signature)
APPLICANT completes section A when
holding/applying for P and S endorsement.
HEALTH CARE PROFESSIONAL completes section B for
applicant holding/applying for S endorsement.
Alcohol or other drug abuse or dependency within the past 12 months
Alcohol or other drug abuse or dependency within the past 12–24 months not controlled by treatment
Neuro/Muscular disease, e.g., ALS, MS, Head Trauma
Diabetes or elevated blood sugar controlled by: Diet Pills Insulin
Heart disease or heart attack, stroke, other cardiovascular condition
Heart surgery (valve replacement/bypass, angioplasty, pacemaker, AICD) Date:
Pulmonary disease or condition, positive TB communicable form, emphysema, COPD
Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring
Loss of body control, or altered consciousness Date:
Seizures, epilepsy Date of last episode:
Blood pressure over 180/105 (If yes, provide 3 BP readings taken over a 2-week period, separated by at least 1 day)
Mental/Emotional Conditions
Missing or impaired hand, arm, foot, leg
Inability to hear instructions given in normal conversational tone Corrected by Hearing aid
Any medication that would interfere with the safe operation of a school bus
For any YES answers, indicate onset date, diagnosis and any current limitations. List all medications (including over-the-counter medications) used regularly or recently.
I certify that the answers and statements made on this report are true
and correct. I authorize the examining health care professional to
release full details of an examination upon request to my employer,
the School Board and the Wisconsin Department of Transportation.
(Applicant Signature) (Date – m/d/yyyy)
HEALTH CARE
PROFESSIONAL:
For any YES answers, indicate onset date, diagnosis and any current limitations. List all medications (including over-the-counter medications) used regularly or
recently. Please use the back of this form for additional comments, if needed.
Would you recommend any additional medical evaluation?
This report must be based on an examination conducted within the past 90 days. I certify that I have examined this applicant and that I am licensed to practice
(MD, DO, PA-C, DC, MSN, FNP, GNP, RN).
(Area Code) Office Telephone No.
