DOT Physical Examination for Commercial Drivers
A DOT physical examination for commercial drivers must be performed by a certified medical examiner listed on the FMCSA National Registry and includes mandatory screening for conditions that impair safe driving, with particular emphasis on obstructive sleep apnea screening based on objective BMI criteria, cardiovascular disease, diabetes, vision and hearing standards, and neurological conditions that could cause loss of consciousness. 1, 2
Examiner Qualifications
- Only allopathic physicians, osteopathic physicians, physician assistants, advanced practice nurses, or chiropractors who are certified and listed on the FMCSA National Registry may perform DOT physical examinations. 3
- Medical examiners must complete FMCSA-specific training on physical qualification standards, pass a certification test, and recertify every 10 years with refresher training every 5 years. 3
- For OSA screening specifically, the American Academy of Sleep Medicine recommends that allopathic and osteopathic physicians, nurse practitioners, and physician assistants are most appropriate, and explicitly recommends against chiropractors performing this component due to insufficient training in physiology and pharmacology. 1
Mandatory Screening Components
Obstructive Sleep Apnea (Primary Criteria)
All commercial drivers meeting any of the following must be immediately referred to a board-certified sleep medicine specialist: 1, 2
- BMI ≥ 40 kg/m² (automatic referral regardless of symptoms) 1, 2
- BMI ≥ 33 kg/m² PLUS either:
- Any sleepiness-related crash, accident, off-road deviation, or rear-ending another vehicle 1, 2
- Admitted fatigue or sleepiness during duty periods 1, 2
Obstructive Sleep Apnea (Secondary Criteria)
Drivers with BMI 28-33 kg/m² should be referred if they have ≥2 of the following risk factors: 2
- Neck circumference ≥17 inches (men) or ≥15.5 inches (women) 2
- Modified Mallampati classification 3 or 4 2
- Small or recessed jaw 2
- Hypertension 2
- Type 2 diabetes with obesity 2
- Cardiovascular disease 2
- Untreated hypothyroidism 2
- Age ≥42 years 2
- Male sex or postmenopausal female 2
- Family history of OSA 2
Critical Pitfall for OSA Screening
Do not accept "I don't snore" or "I'm not sleepy" as sufficient to rule out OSA in obese commercial drivers—screening must be based on objective BMI and clinical criteria at every medical evaluation. 1, 2 Self-reported symptoms are unreliable, with documented cases of drivers having AHI of 164 events/hour with normal Epworth Sleepiness Scale scores. 1
Cardiovascular and Metabolic Assessment
Conditions Requiring Limited Certification or Specialist Clearance
The following conditions significantly increase likelihood of limited medical certification or disqualification: 4
- Heart disease (OR = 5.19 for limited certification) 4
- Vascular disease (OR = 11.83 for limited certification) 4
- Stroke history (OR = 6.73 for limited certification) 4
- Diabetes requiring medication (common cause of limited certification) 4
- Hypertension requiring medication (common cause of limited certification) 4
Diabetes-Specific Requirements
Insulin-requiring diabetes is automatically disqualifying for interstate commercial driving, regardless of control. 5 Drivers with diabetes managed by oral medications or diet require assessment of hypoglycemia risk, with particular attention to any history of hypoglycemia behind the wheel. 1, 6
Neurological Assessment
Conditions Causing Loss of Consciousness
Drivers with conditions causing altered perception or loss of consciousness require comprehensive evaluation: 6, 4
- Seizure disorders (OR = 10.18 for limited certification) 4
- Syncope (must assess frequency, triggers, and presence of prodrome) 1
- Neurological conditions (OR = 18.51 for limited certification) 4
Commercial drivers face more stringent restrictions than private drivers because of vehicle weight, driving duration, and public safety impact. 1
Medication Review
Automatically Disqualifying or Requiring Specialist Clearance
The following medication classes require careful evaluation or specialist clearance: 4
- Opioid use (OR = 7.30 for limited certification) 4
- Benzodiazepine use (OR = 7.30 for limited certification) 4
- Any medication causing sedation or altered alertness 6
Vision and Sensory Function
The examination must assess: 6
- Visual acuity (specific DOT standards apply) 6
- Peripheral vision 6
- Sensation in the right foot for vehicle operation 6
Musculoskeletal Assessment
Musculoskeletal conditions that impair ability to safely operate a commercial vehicle have OR = 5.13 for limited certification. 4 The examiner must assess whether the driver can safely perform all driving and non-driving work-related tasks. 7
Multiple Comorbidities
Drivers with ≥2 medical conditions from the 13 most common disqualifying conditions have dramatically increased likelihood of limited certification (OR = 122.35) or disqualification (OR = 4.91). 4 This includes obesity >35 kg/m², hypertension, diabetes, heart disease, sleep apnea, neurological conditions, and medication use. 4
Certification Duration
Medical certification length varies based on condition severity and control: 4, 8
- Well-controlled single conditions may receive 2-year certification 4
- Poorly controlled or multiple conditions typically receive 3-6 month certification requiring re-evaluation 4
- Conditions requiring specialist clearance may receive temporary certification pending specialist evaluation 5
Documentation Requirements
The examining physician must: 6
- Attest that the driver meets medical fitness standards for commercial driving 6
- Document any recommended restrictions or modifications 6
- Provide written documentation of conditions that may impair safe driving 6
- Recommend periodic follow-up intervals for ongoing monitoring 6
Examiner Liability Protection
Physicians performing DOT examinations are typically provided immunity from civil and criminal actions resulting from their medical certification decisions, but must follow federal standards to maintain this protection. 6, 5 The examiner's primary responsibility is to public safety, not to the driver's employment interests. 5