CA DMV DL 546A Form PDF Details

Navigating the requirements for maintaining or obtaining a driver's license in California involves various steps, including meeting specific health standards. The Physician’s Health Report, form DL 546A, issued by the California Department of Motor Vehicles (DMV), is a crucial document in this process. It is designed for non-commercial licensing and requires a physician’s detailed assessment of the applicant's health to ensure they are fit to drive. This form addresses several critical health questions, ranging from visual and auditory acuity to more complex issues such as cardiovascular health, diabetes management, and neurological conditions that could impair driving ability. Applicants must submit this form every two years, although driving school instructors have a three-year interval. The form also inquires about the use of habit-forming drugs or a history of alcoholism and how these might affect driving capabilities. The DL 546A includes sections for patient information, a comprehensive health questionnaire that the physician must fill out, and lines for both physician and applicant signatures, establishing the accuracy of the provided information under penalty of perjury. By compiling a wide range of health metrics, the DL 546A form plays a vital role in the DMV’s commitment to public safety by ensuring that only those who are physically and mentally fit are behind the wheel.

QuestionAnswer
Form Name CA DMV DL 546A Form
Form Length 2 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 30 sec
Other names dl546 a form, dmv 546 form, dl 546a, dmv dl 546a health questionnaire

Form Preview Example

STATE OF CALIFORNIA

DEPARTMENT OF MOTOR VEHICLES®

A Public Service Agency

PHYSICIAN’S HEALTH REPORT

DO NOT use this form for Commercial Licensing Requirements.

546A

DMV USE ONLY

Updated by

PHYSICIAN’S INSTRUCTIONS: Please complete the form and check “Yes” or “No” to each question and explain any “Yes” answer(s) in the space provided on the form, or on another piece of paper. Applicant must submit a completed health questionnaire every two years. Exception: Driving School Instructors must complete a health questionnaire every three years.

SECTION 1 — PATIENT INFORMATION

trUe fUll Name

date of birth

driver liceNse NUmber

address

citY

state

ZiP code

daYtime PhoNe

()

SECTION 2 — HEALTH QUESTIONS

1. does patient have difficulty recognizing the colors of red, green, and amber used in traffic signal lights and Yes No devices?..............................................................................................................................................................

2. is patient’s side (peripheral) vision less than 70° for either eye? ........................................................................

3. does patient have difficulty perceiving a forced whispered voice in the patient’s better ear, with or without a

hearing aid, at not less than ive (5) feet?...........................................................................................................

4. does patient have an acuity impairment in either eye that is not correctable to visual acuity of 20/40 or better? ...

5. does patient:

a. have a missing foot, leg, hand, inger or arm? ...............................................................................................

b. have any impairment of a hand, inger, arm, foot, leg or any other limitation? ...............................................

6. does patient have diabetes requiring insulin? ....................................................................................................

a. has patient had a hypoglycemic episode or any other adverse reaction related to diabetes in the last three (3)

years? .................................................................................................................................................................

7. has patient had a heart attack, angina, coronary insufficiency, thrombosis, stroke, other heart problem, or

cardiovascular disease? .....................................................................................................................................

if “yes,” has patient had labored breathing, fainting, collapse, congestive heart failure, or other symptoms in the

last three (3) years? ............................................................................................................................................

8. has patient been diagnosed with a respiratory condition, such as emphysema, chronic asthma, or

tuberculosis?.......................................................................................................................................................

if “yes,” is patient’s respiratory condition likely to interfere with patient’s ability to drive a motor vehicle

safely? ...........................................................................................................................................................

9. has patient been diagnosed with high blood pressure of 140/90 or higher? ......................................................

10. has patient ever been diagnosed with rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular

disease? .............................................................................................................................................................

if “yes,” is the condition likely to interfere with patient’s ability to drive a motor vehicle safely?...........................

11. has patient been diagnosed with any mental, nervous, organic or functional disease, or psychiatric disorder?....

if “yes,” is the condition likely to interfere with patient’s ability to drive a motor vehicle safely?...........................

12. has patient been diagnosed with epilepsy or any other condition that may cause lapse of consciousness or loss

of control?............................................................................................................................................................

if “yes,” has there been a lapse of consciousness or loss of control in the last three (3) years?.........................

13. does patient use a controlled substance, amphetamine, narcotic, or any other habit-forming drug? ................

if “yes” will the drug interfere with the patient’s ability to drive a motor vehicle safely? .......................................

14. does patient have a history or diagnosis of alcoholism? ....................................................................................

dl 546a (rev. 11/2012) WWW

PHYSICIAN’S HEALTH REPORT (CONT.)

Visual Acuity: must be at least 20/40 in each eye with/without corrective lenses.

Blood Pressure: if consistently 140/90 mm. hg. or higher, further tests may be necessary to determine if driver is qualiied.

UNCORRECTED

both

20/

 

 

left

20/

 

 

right

20/

 

 

 

 

 

 

CORRECTED

CONTACTS?

 

 

20/

 

 

Yes

No

 

20/

 

 

are the lenses well adapted and

20/

 

 

tolerated?

Yes

No

systolic

 

diastolic

 

 

 

exPlaiN aNY “Yes” aNswers here

i have examined the applicant and found that the patient has no physical impairment or condition that would preclude them from:

Driving a House Car 40+ feet Being a Driving School Instructor

PhYsiciaN’s Name (PLEASE PRINT)

PhYsiciaN’s office address

date of last visit

mo.Year

PhYsiciaN’s PhoNe NUmber

()

PhYsiciaN’s siGNatUre

X

date of exam

liceNse or certificate NUmber/issUiNG state

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I hereby give consent to the release of medical information by the above named physician.

driver’s siGNatUre

X

DMV examiNer’s siGNatUre

USE X

date

id NUmber

office

date

 

 

 

dl 546a (rev. 11/2012) WWW

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Find out how to complete dl 546 portion 1

2. Just after the last section is filled out, go on to type in the relevant information in these: has patient had a heart attack, has patient been diagnosed with a, has patient been diagnosed with, has patient ever been diagnosed, has patient been diagnosed with, has patient been diagnosed with, does patient use a controlled, does patient have a history or, and dl a rev WWW.

Part no. 2 in completing dl 546

3. The next segment is considered fairly easy, UNCORRECTED both left right, CORRECTED , exPlaiN aNY Yes aNswers here, CONTACTS, Yes, are the lenses well adapted and, Yes, Blood Pressure if consistently mm, systolic, diastolic, i have examined the applicant and, Driving a House Car feet Being a, PhYsiciaNs Name PLEASE PRINT, PhYsiciaNs office address, and date of last visit - all of these blanks must be filled in here.

Step # 3 in completing dl 546

Be very mindful when filling out systolic and are the lenses well adapted and, since this is where a lot of people make a few mistakes.

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