California DMV DL 546 Form PDF Details

In the vast and often complex world of navigating through California's Department of Motor Vehicles (DMV) requirements, the DL 546 form plays a crucial role for residents aiming to obtain or renew their driving license. Known formally as the Health Questionnaire, this critical document serves as a tool to ensure the driver’s health status is in alignment with the safety standards set forth for operating a vehicle. The form is meticulously designed to capture essential health-related information, stretching from basic queries about an applicant's ability to recognize traffic light colors to more profound health concerns that might impair driving abilities, such as vision impairments, hearing difficulties, and serious health conditions like diabetes, cardiovascular diseases, or neurological disorders. To complete this form, applicants must answer a series of yes or no questions, providing additional details for any affirmative responses to clarify their medical circumstances. It’s not just a formality; a “yes” can trigger a review by the DMV, possibly requiring further input from a physician to corroborate the applicant's medical fitness for driving. The inclusion of details on conditions affecting limbs, vision, and even mental health highlights the DMV's comprehensive approach to ensuring public safety on the roads. With a requirement to update this information every two years, the DL 546 form stands as a testament to California’s ongoing commitment to balancing individual mobility needs with the collective well-being of its commuters.

QuestionAnswer
Form Name California DMV DL 546 Form
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names dmv 546 health questionnaire, dmv medical questionnaire, ca dmv health questionnaire fillable 546, dmv health questionnaire, california dmv health questionnaire

Form Preview Example

STATE OF CALIFORNIA

DEPARTMENT OF MOTOR VEHICLES®

A Public Service Agency

HEALTH QUESTIONNAIRE

DO NOT use this form for Commercial Licensing Requirements.

546

DMV USE ONLY

updated by ________

The applicant completes this form.

INSTRUCTIONS: Please check “yes” or “no” to each question and explain any “yes” answer(s) in the space provided on the bottom of the form, or on another piece of paper. if you are not sure how to answer a speciic question, please contact your physician for assistance. “yes” answers to any question may require dmv to contact your physician about your medical qualiications before dmv can issue you a license. You must submit a completed health questionnaire every two years.

PLEASE TELL US ABOUT YOURSELF:

true full name

address

date of birth

mo______ day______ year______

driver license number

daytime Phone

()

 

HEALTH QUESTIONS

 

YES NO

1.

do you have difficulty recognizing the colors of red, green, and amber used in traffic signal lights and devices?

2.

is your side (peripheral) vision less than 70° for either eye?

3.

do you have difficulty perceiving a forced whispered voice in your better ear, with or without a hearing aid, at not less

 

than ive (5) feet?

4.

do you have a vision impairment in either eye that is not correctable to visual acuity of 20/40 or better?

5.

do you:

 

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

 

b. have an impairment of a hand or inger?

 

c. have any other impairment of an arm, foot, leg or any other limitation?

6.

do you have diabetes requiring insulin?

 

a. have you had a hypoglycemic episode in the last three (3) years?

 

b. have you had any other adverse reaction related to diabetes in the last three (3) years?

7.

have you had a heart attack, angina, coronary insufficiency, thrombosis, stroke, other heart problem, or cardiovascular

 

disease?

 

if “yes,” have you had labored breathing, fainting, collapse, congestive heart failure, or other symptoms in the last

 

three (3) years?

8.

have you been diagnosed with a respiratory condition, such as emphysema, chronic asthma, or tuberculosis?

 

if “yes,” is your respiratory condition likely to interfere with your ability to drive a motor vehicle safely?

9.

have you been diagnosed with high blood pressure?

 

if “yes,” is your blood pressure usually 140/90 or higher?

10.

have you ever been diagnosed with rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular disease?

 

if “yes,” is the condition likely to interfere with your ability to drive a motor vehicle safely?

11.

have you been diagnosed with any mental, nervous, organic or functional disease, or psychiatric disorder?

 

if “yes,” is your condition likely to interfere with your ability to drive a motor vehicle safely?

12.

have you been diagnosed with epilepsy or any other condition that may cause lapse of consciousness or loss of control? ...

 

if “yes,” have you had a lapse of consciousness or loss of control in the last three (3) years?

13.

do you use a controlled substance, amphetamine, narcotic, or any other habit-forming drug?

 

a. if “yes”, did your doctor prescribe the drug?

 

b. did your doctor advise you NOT to drive when taking the drug?

14.

do you have a current clinical diagnosis of alcoholism?

 

if “yes,” when was your last drink of an alcoholic beverage? _______________________________________________

exPlain any “yes” answers here.

Physician’s name (PLEASE PRINT)

date of last visit

 

mo___________ year_____

 

 

Physician’s office address

Physician’s Phone number

 

(

)

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

 

 

date

X

 

 

 

 

 

 

 

 

 

DMV

examiner’s siGnature

id number

office

date

USE

X

 

 

 

 

 

 

 

 

dl 546 (rev.6/2011) WWW

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