DOT Physical Pre-Registration

Please fix the following:

Before your visit

Please complete this form before your DOT physical. It takes about 10 minutes. Your answers are sent securely to Unif Health and reviewed by the Medical Examiner during your exam. Answer every question honestly — the examiner will discuss any “Yes” answers with you.

At your visit, bring: a valid photo ID, glasses/contacts or hearing aids if you use them, and any specialist records (for example, CPAP report or heart clearance).

1. Your Appointment

Appointment date

Time (if known)

Employer or company (if any)

Where does your job require you to drive a commercial vehicle?

Only within California Outside California (to or through other states) Not sure

If you're not sure, ask your employer. The examiner will confirm with you at your visit.

2. Driver Information

First Name

Last Name

Middle Initial

Date of Birth Street Address

City

State/Province

Zip Code

Phone

E-Mail

✉️Your certificate will be emailed to you. A copy of your Medical Examiner’s Certificate will be emailed to the address above after your exam. We are fully electronic — no paper copies are printed.

Driver’s License Number

Issuing State/Province

CLP/CDL Applicant/Holder?

Answer “Yes” if you hold or are applying for a commercial learner’s permit (CLP) or commercial driver’s license (CDL).

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?

3. Driver’s License Photo

Take a clear photo of your driver’s license (or CDL). Place it on a dark, flat surface, avoid glare, and make sure all four corners and the text are visible. Please still bring the physical license to your visit.

Front of license

Take Photo

Back of license (optional)

Take Photo

4. Driver Health History

Have you ever had surgery? If “yes,” please list and explain below.

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)? If “yes,” please describe below.

List each medication and dose:

Do you have or have you ever had:

Other health condition(s) not described above:

Please describe:

Did you answer “yes” to any of questions 1-32? If so, please comment further on those health conditions below:

5. CMV Driver’s Signature

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.

I have read and agree to the certification above. Print your full name Sign below with your finger

Use your finger or mouse

Your information is protected health information and is used only for your DOT examination at Unif Health.

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Your answers were sent securely to Unif Health.

Your confirmation number

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Your visit

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Please arrive 10 minutes early with your photo ID.

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Unif Health – Berkeley2320 Woolsey Street, Suite 100, Berkeley, CA 94705
Open in Maps · (510) 778-7064

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What to bringPhoto ID; glasses, contacts or hearing aids if you use them; and any specialist records (for example, a CPAP report or heart clearance).

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Questions?Email us at info@gounif.com

See you soon! 👋

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Welcome! Let's get you ready for your DOT physical.