Clinic Platoforms
First Name*
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I understand the copies of the records indicated above will be communicated to: New Prime Inc. dba PRIME INC 2740 N Mayfair Ave Springfield, MO 65803 *
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Date of Birth*
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what is your date of birth?
Age*
How old are you?
Street Address*
What is your street address?
City*
What city do you live in?
State*
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What state do you live in?
Zip code*
What is your zip code?
Phone*
What is your phone number?
Social security number*
Please enter your social security number
Driver's License Number*
Please enter your driver's license number
Issuing State
Choose One
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
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New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
In what state was your drivers license issued?
CLP/CDL Applicant/Holder*
Yes
No
Are you currently applying or do you have a CLP or CDL?
E-mail address
Has your USDOT/FMCSA medical certificate ever been issued for less than 2 years or denied?*
Yes
No
Has your DOT card ever been less than 2 years?
Have you EVER had surgery?*
Yes
No
This includes childhood surgeries as well. If you are not sure please mark yes and list below.
If you have had any surgeries please list
If you have had any surgeries please list
Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?*
Yes
No
If you are taking any medications please list
If you are taking any medications please list
Do you have or have you ever had:
1. Head/brain injuries or illnesses (e.g., concussion)*
Yes
No
Have you ever had a head or brain injury or any head or brain illness?
2. Do you have or have you ever had seizures, epilepsy?*
Yes
No
Have you ever had seizures or been on seizure medication?
3. Do you have or have you ever had eye problems (except glasses or contacts)*
Yes
No
Do you have or have you ever had eye problems (except glasses or contacts)
4. Do you have or have you ever had ear and/or hearing problems?*
Yes
No
Do you have or have you ever had ear and/or hearing problems?
5. Do you have or have you ever had heart disease, heart attack, bypass or other heart problems?*
Yes
No
Do you have or have you ever had heart disease, heart attack, bypass or other heart problems?
6. Do you have or have you ever had a pacemaker, stents, implantable devices or other heart procedures?*
Yes
No
Do you have or have you ever had a pacemaker, stents, implantable devices or other heart procedures?
7. Do you have or have you ever had high blood pressure?*
Yes
No
Do you have or have you ever had high blood pressure?
8. Do you have or have you ever had high cholesterol?*
Yes
No
Do you have or have you ever had high cholesterol?
9. Do you have or have you ever had chronic (long-term) cough, shortness of breath or other breathing problems?*
Yes
No
Do you have or have you ever had chronic (long-term) cough, shortness of breath or other breathing problems?
10. Lung disease (e.g., asthma)*
Yes
No
Do you have lung disease or asthma?
11. Do you have or have you ever had kidney problems, kidney stones or pain/problems with urination?*
Yes
No
Do you have or have you ever had kidney problems, kidney stones or pain/problems with urination?
12. Do you have or have you ever had stomach, liver or digestive problems?*
Yes
No
Do you have or have you ever had stomach, liver or digestive problems?
13. Do you have or have you ever had diabetes or blood sugar problems?*
Yes
No
Do you have or have you ever had diabetes or blood sugar problems?
13.1 Do you use or have you ever had to use insulin?*
Yes
No
Do you use or have you ever had to use insulin?
14. Do you have or have you ever had issues with anxiety, depression, nervousness or other mental health problems?*
Yes
No
Do you have or have you ever had issues with anxiety, depression, nervousness or other mental health problems?
15. Do you have or have you ever had issues with fainting or passing out?*
Yes
No
Do you have or have you ever had issues with fainting or passing out?
16. Do you have or have you had dizziness, headaches, numbness, tingling, or memory loss?*
Yes
No
Do you have or have you had dizziness, headaches, numbness, tingling, or memory loss?
17. Do you have or have you ever had unexplained weight loss?*
Yes
No
Do you have or have you ever had unexplained weight loss?
18. Do you have or have you ever had a stroke, mini-stroke(TIA), paralysis, or weakness?*
Yes
No
Do you have or have you ever had a stroke, mini-stroke(TIA), paralysis, or weakness?
19. Do you have or have missing or limited use of arm, hand, finger, leg, foot or toe?*
Yes
No
Do you have or have missing or limited use of arm, hand, finger, leg, foot or toe?
20. Do you have or have you ever had neck or back problems?*
Yes
No
Do you have or have you ever had neck or back problems?
21. Do you have or have you ever had bone, muscle, joint or nerve problems?*
Yes
No
Do you have or have you ever had bone, muscle, joint or nerve problems?
22. Do you have or have you ever had blood clots or bleeding problems?*
Yes
No
Do you have or have you ever had blood clots or bleeding problems?
23. Do you have or have you ever had cancer?*
yes
No
Do you have or have you ever had cancer?
24. Do you have or have you ever had chronic(long-term) infection or other chronic disease?*
Yes
No
do you have or have you ever had chronic(long-term) infection or other chronic disease?
25. Do you have or have you ever had sleep disorders, pauses in breathing while asleep, daytime sleepiness or loud snoring?*
Yes
No
Do you have or have you ever had sleep disorders, pauses in breathing while asleep, daytime sleepiness or loud snoring?
26. Have you ever had a sleep test (e.g., sleep apnea)?*
Yes
No
Have you ever been checked or told to get checked for sleep apnea?
27. Have you ever spent a night in the hospital?*
Yes
No
Have you ever spent a night in the hospital?
28. Have you ever had a broken bone?*
Yes
No
Have you ever had a broken bone?
29. Have you ever used or do you now use tobacco?*
Yes
No
Have you ever used or do you now use tobacco?
30. Do you currently drink alcohol?*
Yes
No
Do you currently drink alcohol?
31. Have you used an illegal substance within the past two years?*
Yes
No
Have you used an illegal drugs including marijuana within the past two years?
32. Have you ever failed drug test or been dependent on an illegal substance?*
Yes
No
Have you ever failed drug test or been dependent on an illegal substance?
Do you have any health conditions not described in the previous questions?*
Yes
No
Do you have any health conditions not described in the previous questions?
If you answered yes please list below
If you answered yes please list below
Did you answer "yes" to questions 1-32?*
Yes
No
Did you answer "yes" to questions 1-32?
If you answered "yes" to a question in 1-32 please explain
If you answered "yes" to a question in 1-32 please explain
I certify that the above information is accurate and complete. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate, that submission of fraudulent or intentionally false information is a violation of 49 CFR 390.35, and that submission of fraudulent or intentionally false information may subject me to civil or criminal penalties under 49 CFR 390.37 and 49 CFR 386 Appendices A and B.*
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