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Driver Medical Evaluation DS 326 - California
| Driver Medical Evaluation Form. This is a California form and can be used in Administrative Hearings And Reexaminations Statewide . |
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STATE OF CALIFORNIA PHYSICIAN RETURN FORM TO: ® A Public Service Agency DEPARTMENT OF MOTOR VEHICLES DRIVER MEDICAL EVALUATION DEPARTMENT OF MOTOR VEHICLES Licensing Operations Division Driver Safety Branch P. O. Box 934345 MS J-234 Sacramento, CA 95818 (Medical information is CONFIDENTIAL under Section 1808.5 CVC) INSTRUCTIONS TO THE DRIVER: Please take this form to the medical professional most familiar with your health history and current medical condition. Before giving this form to your medical professional, complete and sign Sections 1-3. PLEASE PRINT LEGIBLY. INSTRUCTIONS TO THE MEDICAL PROFESSIONAL: Please complete Sections 5-13, on pages 2 through 5. The Department of Motor Vehicles' records indicate your patient may have a condition that could affect the safe operation of a motor vehicle. In this case, the department is concerned about the following condition: 1. DRIVER INFORMATION NAME (LAST, FIRST, MIDDLE) DRIVER LICENSE NO. BIRTH DATE FIELD FILE RETURN BY: STREET ADDRESS CITY ZIP PATIENT'S DAYTIME OR HOME PHONE NO. DRIVER MUST COMPLETE HEALTH HISTORY BELOW. (Please explain any "YES" answers) YES NO YES NO Head, neck, spinal injury, disorders or illnesses Seizure, convulsions, or epilepsy Dizziness, fainting, or frequent headaches Eye problem (except corrective lenses) Cardiovascular (heart or blood vessel) disease Heart attack, stroke, or paralysis Lung disease (include tuberculosis, asthma or emphysema) Nervous stomach, ulcer, or digestive problems Diabetes or high blood sugar Kidney disease, stones, blood in urine, or dialysis Muscular disease Any permanent impairment Nervous or psychiatric disorder Regular or frequent alcohol use Problems with the use of alcohol or drugs Other disorders or diseases Any major illness, injury, or operations in last 5 years Currently taking medications EXPLANATION: (Include onset date, diagnosis, medication, doctor's name and address and any current condition or limitation. Attach additional sheet, if needed). I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I further certify that all information concerning my health is true and correct. DATE DRIVER'S SIGNATURE X 2. DRIVER'S ADVISORY STATEMENT Medical information is required under the authority of Divisions 6 and 7 of the California Vehicle Code. Failure to provide the information is cause for refusal to issue a license or to withdraw the driving privilege. All records of the Department of Motor Vehicles, relating to the physical or mental condition of any person, are confidential and not open to public inspection (California Vehicle Code Section 1808.5). Information used in determining driving qualifications is available to you and/or your representative with your signed authorization. The department has sole responsibility for any decision regarding your driving qualifications and licensure. The department will also consider non-medical factors in reaching a decision. 3. MEDICAL INFORMATION AUTHORIZATION MEDICAL PROFESSIONAL, HOSPITAL, OR MEDICAL FACILITY (NAME AND ADDRESS) DATE MEDICAL RECORD/PATIENT FILE NO. I hereby authorize my medical professional or hospital to answer any questions from the Department of Motor Vehicles, or its employees, relating to my physical or mental condition, and/or drug and/or alcohol use, and to release any related information or records to the Department of Motor Vehicles or its employees. Any expense involved is to be charged to me and not to the Department of Motor Vehicles. I hereby authorize the Department of Motor Vehicles to receive any information relating to my physical or mental condition, and/or drug and/or alcohol use or abuse, and to use the same in determining whether I have the ability to operate a motor vehicle safely. NOTE: You may wish to make a copy of the completed Driver Medical Evaluation for your records. SIGNED DATE X DS 326 (REV. 11/2010) WWW Page 1 of 5 American LegalNet, Inc. www.FormsWorkFlow.com SECTIONS 5 -13 TO BE COMPLETED BY PHYSICIAN, PHYSICIAN'S ASSISTANT OR ADVANCED PRACTICE REGISTERED NURSE 4. MEDICAL PROFESSIONAL'S MEDICAL EVALUATION INSTRUCTIONS INSTRUCTIONS TO THE MEDICAL PROFESSIONAL (MP): The Department of Motor Vehicles' records indicate your patient may have a condition that could affect the safe operation of a motor vehicle. (See Instructions to the Medical Professional, page 1 for the specific medical condition that is a concern to the department.) With your assistance, the department hopes to resolve the matter with a minimum of inconvenience to all concerned. The Health History and Medical Information Authorization sections on page 1 must be completed and signed by the patient before you complete this Driver Medical Evaluation form. Your experience and knowledge of the patient's condition, results of medical examinations and treatment plans, will be of great value in assisting the department to determine a proper licensing decision. PLEASE ANSWER ALL QUESTIONS on this form. If questions do not apply, indicate "N/A". You may furnish a narrative report if you prefer, but please include all information pertinent to your patient. The department has sole . responsibility for any decision regarding the patient's driving qualifications and licensure. The department will also consider non-medical factors in reaching a decision. 5. VISION VISUAL ACUITY (without bioptic telescope) Without Lenses With Present Lenses ANY EYE INJURY OR DISEASE? (LIST) BOTH EYES 20/ 20/ RIGHT EYE 20/ 20/ LEFT EYE 20/ 20/ IS FURTHER EYE EXAMINATION SUGGESTED? Yes 6. TREATMENT BY OTHER MEDICAL PROFESSIONAL(S) IS THIS PATIENT BEING TREATED FOR ANY CONDITION BY ANOTHER MP? No Yes No IF YES, PLEASE INDICATE NAME OF TREATING MP(S) CONDITION BEING TREATED 7. TREATMENT UNDER YOUR SUPERVISION DIAGNOSIS (IF THE DIAGNOSIS IS A DISORDER CHARACTERIZED BY LAPSES OF CONSCIOUSNESS, DEMENTIA, OR DIABETES, COMPLETE PAGE 3,4 OR 5.) DO YOU NEED TO SEE YOUR PATIENT AT REGULAR INTERVALS? IF YES, HOW OFTEN? Yes PROGNOSIS No IS THE CONDITION Improving Stable Worsening or deteriorating Subject to change (IF MULTIPLE CONDITIONS, PLEASE DESCRIBE STATUS AND PROGNOSIS IN COMMENTS BELOW.) MANIFESTATIONS (SYMPTOMS): (PRESENT) (PAST) MAY CONDITION IMPAIR VISION? Yes HOW LONG HAS THIS PERSON BEEN YOUR PATIENT? DATE OF LAST EXAMINATION No IS YOUR PATIENT UNDER A CONTROLLED MEDICAL PROGRAM? HOW LONG HAS CONTROL BEEN MAINTAINED? Yes Yes No IS THE PATIENT KNOWLEDGEABLE ABOUT THE MEDICAL C
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