Form DL 546A at a glance
What it is: This form is the Physician's Health Report; do not use this form for Commercial Licensing Requirements.
A filled-in Form DL 546A example: a driving school instructor's health report
How to fill out Form DL 546A, box by box
Tap a group of boxes to open it, and a picture to see it full size.
Section 1 - Patient Information
In Section 1 - Patient information, enter the true full name, date of birth, driver license number, address, city, state, zip code and daytime phone.
Section 2 - Health Questions
Fill the form and check "Yes" or "No" to each question and explain any "Yes" answer(s) in the space provided on the form (EXPLAIN ANY "YES" ANSWERS HERE), or on another piece of paper. The applicant must submit a completed health questionnaire every two years; Driving School Instructors must complete a health questionnaire every three years.
Section 2 - Health questions: 1. Does patient have difficulty recognizing the colors of red, green, and amber used in traffic signal lights and 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 five (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, finger or arm? b. Have any impairment of a hand, finger, 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?
Visual acuity and blood pressure
Enter the visual acuity, uncorrected and corrected, both, left and right; the acuity must be at least 20/40 in each eye with/without corrective lenses. Check "Yes" or "No": contacts? and are the lenses well adapted and tolerated?
Enter the blood pressure: systolic and diastolic; if consistently 140/90 mm. Hg. or higher, further tests may be necessary to determine if driver is qualified.
Physician's signature
After "I have examined the applicant and found that the patient has no physical impairment or condition that would preclude them from:", check Driving a House Car 40+ feet, or check Being a Driving School Instructor.
Fill the physician's name (please print), the date of last visit (mo. year), the physician's office address, the physician's phone number, the date of exam and the license or certificate number/issuing state.
The physician signs on the Physician's signature line, certifying (or declaring) under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
Driver's signature
The driver signs on the Driver's signature line and writes the Date, to give consent to the release of medical information by the above named physician.
Common questions about Form DL 546A
When is this form not the right one?
This form is the Physician's Health Report; do not use this form for Commercial Licensing Requirements.
Sources
[1] Form DL 546A, Physician's Health Report (the Official source link on this page).