California Dmv Dl 546 Form – Fill Out and Use This PDF

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? _______________________________________________

Physician’s name (PLEASE PRINT)

date of last visit

mo___________ year_____

Physician’s office address

Physician’s Phone number

(

)

driver’s siGnature

date

X

DMV

examiner’s siGnature

id number

office

date

USE

X