FREE DOT Readiness Assessment Request

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Complete this form to request a FREE In Office DOT Readiness Assessment.

The free in-office assessment is not a DOT physical. It is a brief screening to identify common issues that may unnecessarily disqualify drivers or shorten their certification period. We will check height, weight, blood pressure, vision, hearing and review your medical history.

Full Name (Required) *

Mobile Phone (Required) *

When does your DOT Medical Card expire? (Example 01/01/2030, already expired or first medical card) *

Do you have or have ever had the following: *

High Blood Pressure or take BP medication

Diabetes or pre-diabetes

Insulin use

Tested positive for sleep apnea

Heart disease, heart attack, bypass, or other heart problems

Stroke, mini stroke (TIA), paralysis, or weakness

Blood clots or bleeding issues

Brain illness or injury (Example concussion)

Seizures, epilepsy

Chronic lung disease (Example asthma, emphysema, COPD)

Anxiety, depression, nervousness, ADHD, or other mental health problems

Fainting, passing out, dizziness, or other memory loss

Missing or limited use of arm, hand, finger, leg, foot, or toe

Require the use of a brace, crutch, cane to walk

Cancer

Failed a drug test or used an illegal substance in the past two years (including marijuana)

Heavy drinker

None

Required

When is the best time to call to reserve your appointment? *

If you take prescription medications, please list all medications, dosage, and what they treat. If no prescribed medications, please type NONE. *

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