The DOT long form is a multi-page government document officially called the Medical Examination Report (MER) Form, designated MCSA-5875. It’s the paperwork a certified medical examiner fills out during a DOT physical for commercial drivers. The form is dense, printed in black and white, and organized into clearly labeled sections that move from driver information at the top through a detailed health history, a full physical exam checklist, and finally the examiner’s certification decision at the end.
What the Form Actually Looks Like
The MCSA-5875 looks like a standard federal government form: tightly spaced text, small checkboxes, and gray-bordered sections with bold headers. Each section is numbered and titled. The first page collects basic driver information (name, date of birth, address, license details) and then moves into a long health history questionnaire. Subsequent pages cover the physical examination findings, testing results, and the examiner’s final determination.
The form uses a mix of yes/no checkboxes, write-in blanks for measurements like blood pressure and visual acuity, and small comment fields where the examiner notes abnormalities. It’s functional, not pretty. If you’ve ever filled out intake paperwork at a doctor’s office, the format will feel familiar, just more standardized and detailed.
The Driver Health History Section
The first major section is a medical history questionnaire that the driver completes before the exam. You’ll check “yes” or “no” to a long list of conditions and symptoms: heart disease, seizures, diabetes, breathing problems, kidney disease, dizziness, fainting spells, sleep disorders, and more. There are also questions about surgical history, current medications, and whether you use tobacco or alcohol.
This section matters because checking “yes” to certain items triggers additional evaluation. If you mark that you have sleep apnea, diabetes requiring insulin, or a history of seizures, the examiner will need more documentation before clearing you. You sign and date this section to certify the answers are truthful.
The Physical Examination Checklist
The next section is the examiner’s territory. It lists 14 body systems, each with a checkbox for normal or abnormal findings:
- General appearance
- Skin
- Eyes
- Ears
- Mouth and throat
- Cardiovascular
- Lungs and chest
- Abdomen
- Genitourinary system, including hernias
- Back and spine
- Extremities and joints
- Neurological system, including reflexes
- Gait
- Vascular system
For each system, the examiner checks a box and writes notes if anything is abnormal. This section also has dedicated fields for recording specific measurements from the vision test, hearing test, blood pressure reading, pulse rate, and urinalysis results.
Vision, Hearing, and Blood Pressure Fields
Several parts of the form have blank fields where the examiner records exact numbers. These are some of the most important parts of the document because they determine whether you qualify and for how long.
For vision, you need at least 20/40 in each eye (with or without corrective lenses), a horizontal field of vision of at least 70 degrees in each eye, and the ability to distinguish standard red, green, and amber traffic signal colors. The form has separate blanks for each eye’s acuity score and whether you wear glasses or contacts.
For hearing, the form records either a forced whisper test (you must hear a whisper from at least 5 feet away in your better ear) or audiometric testing results (no worse than a 40-decibel average loss at key frequencies). There are blanks for both methods.
Blood pressure gets its own field, and the reading directly affects your certification length. A reading under 140/90 allows a full two-year certification. Stage 1 hypertension (140-159 over 90-99) limits you to one year. Stage 2 (160-179 over 100-109) gives you only a three-month window to get it under control, after which you can receive a one-year certification. A reading above 180/110 is disqualifying until you bring it below 140/90, at which point you can be certified in six-month intervals.
The Urinalysis Section
Near the bottom of the exam portion, there’s a small section for urinalysis results. This is not a drug test. The DOT physical urine test checks for glucose and protein levels, which can indicate diabetes or kidney problems. The form has checkboxes for the presence of glucose, protein, and blood in the urine sample. If any of these markers show up, the examiner may require follow-up testing before making a certification decision.
The Examiner’s Determination
The final section is where the medical examiner records their decision. This portion includes checkboxes for whether the driver meets federal physical qualification standards, meets them with certain conditions (like requiring corrective lenses), or does not qualify. The examiner signs, dates, and provides their National Registry number. There’s also space for noting any exemptions or skill performance evaluations the driver holds.
The Long Form vs. the Medical Card
One point of confusion: the DOT long form (MCSA-5875) is not the same thing as the medical card you carry in your wallet. The wallet card is a separate, smaller document called the Medical Examiner’s Certificate, form MCSA-5876. The certificate is essentially a summary card that shows your name, the examiner’s determination, and your medical qualification expiration date.
The examiner must complete both forms for every exam. You receive the original MCSA-5876 certificate to carry with you and submit to your state licensing agency. The MCSA-5875 long form stays on file with the examiner’s office. The long form can be stored without its instruction pages, and the certificate card can be reduced in size as long as all the content remains readable.
If you’re preparing for a DOT physical, you can download a blank copy of the MCSA-5875 directly from the FMCSA website to review before your appointment. Familiarizing yourself with the health history questions ahead of time saves time in the office and helps you gather any medical records you might need to bring along.