Ca Dmv Dl 546A Form PDF Details

If you are looking to obtain a duplicate driver license in California, then you will need to fill out the Ca Dmv Dl 546A Form. This form can be downloaded from the DMV website, and must be filled out completely in order for your request to be processed. In addition, you will need to provide proof of identification and residency. Make sure that you submit your application at a local DMV office, as it is not possible to process them through the mail. Fees for a duplicate driver license vary depending on your age, so make sure to check with the DMV before submitting your application. Thanks for reading!

QuestionAnswer
Form NameCa Dmv Dl 546A Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdl546 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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This form will require specific data to be filled in, hence ensure you take whatever time to type in exactly what is expected:

1. Complete your dmv dl546 with a group of essential blank fields. Note all the necessary information and make sure absolutely nothing is omitted!

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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