Form Ds 326 – Fill Out and Use This PDF

The DS 326 form, or Driver Medical Evaluation form, plays a vital role in ensuring public safety on California roads. It is a confidential document used by the California Department of Motor Vehicles (DMV) to assess whether drivers with certain medical conditions can safely operate a vehicle. Drivers and their medical professionals must complete specific sections of the form, providing detailed health information that aids the DMV in making informed decisions about driving privileges. To start the process of filling out the DS 326 form and ensuring you meet the necessary health requirements for driving in California, click the button below.

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Form Ds 326 PDF Details

Ensuring the safety of all drivers on the road involves a comprehensive evaluation of an individual's ability to operate a vehicle safely, especially when a medical condition might affect this capability. The DS 326 form, also known as the Driver Medical Evaluation form, serves as a crucial tool in this process. Mandated by the Department of Motor Vehicles (DMV) in California, this form requires detailed inputs from both the driver and a medical professional familiar with the driver's health history and current condition. The driver is responsible for providing personal and health history information, while the medical professional completes a thorough evaluation of the driver's medical condition, including vision, cognitive abilities, and any treatments or medications that may influence driving ability. This comprehensive form plays a key role in the DMV's decision-making process regarding an individual's driving privileges, aiming to balance public safety with the rights of drivers. By incorporating both self-reported and professionally assessed health information, the DS 326 form helps to ensure that only those capable of driving safely are allowed to do so, while also keeping medical information confidential, in accordance with California Vehicle Code §1808.5 CVC.

Question	Answer
Form Name	Form Ds 326
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	dmv medical evaluation form, driver medical evaluation ds 326, ca form medical, ds 326

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	DS326
A Public Service Agency	DRIVER MEDICAL EVALUATION
	DRIVER MEDICAL EVALUATION
	(Medical information is CONFIDENTIAL under California Vehicle Code §1808.5 CVC)

INSTRUCTIONS TO THE DRIVER: Please take this form to the medical professional most familiar with your health history and current medical condition. Before giving this form to your medical professional, complete and sign Sections 1-3. PLEASE PRINT LEGIBLY.

INSTRUCTIONS TO THE MEDICAL PROFESSIONAL: Please complete Sections 5-13, on pages 2 through 5. The Department of Motor

Vehicles (DMV) records indicate your patient may have a condition that could affect the safe operation of a motor vehicle. In this case, the

department is concerned about the following condition:
department is concerned about the following condition:				RETURN BY:

PHYSICIAN RETURN FORM TO:				FAX NUMBER:
PHYSICIAN RETURN FORM TO:


SECTION 1 — DRIVER INFORMATION

NAME (LAST, FIRST, MIDDLE)		DRIVER LICENSE NO.	BIRTH DATE		FIELD FILE

STREET ADDRESS	CITY	ZIP	PATIENT’S DAYTIME OR HOME PHONE NO.

DRIVER MUST COMPLETE HEALTH HISTORY BELOW. (Please explain any “YES” answers)

YES	NO		YES	NO

		Head, neck, spinal injury, disorders or illnesses			Kidney disease, stones, blood in urine, or dialysis
		Seizure, convulsions, or epilepsy			Muscular disease
		Dizziness, fainting, or frequent headaches			Any permanent impairment
		Eye problem (except corrective lenses)			Nervous or psychiatric disorder
		Cardiovascular (heart or blood vessel) disease			Regular or frequent alcohol use
		Heart attack, stroke, or paralysis			Problems with the use of alcohol or drugs
		Lung disease (include tuberculosis, asthma or emphysema)			Other disorders or diseases
		Nervous stomach, ulcer, or digestive problems			Any major illness, injury, or operations in last 5 years
		Diabetes or high blood sugar			Currently taking medications

EXPLANATION: (Include onset date, diagnosis, medication, doctor’s name and address and any current condition or limitation. Attach additional sheet, if needed).

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I further certify that all information concerning my health is true and correct.

DATE

DRIVER’S SIGNATURE

SECTION 2 — DRIVER’S ADVISORY STATEMENT

Medical information is required under the authority of Divisions 6 and 7 of the California Vehicle Code (CVC). Failure to provide the information is cause for refusal to issue a license or to withdraw the driving privilege.

All records of the DMV, relating to the physical or mental condition of any person, are confidential and not open to public inspection (CVC §1808.5). Information used in determining driving qualifications is available to you and/or your representative with your signed authorization.

The department has sole responsibility for any decision regarding your driving qualifications and licensure. The department will also consider non-medical factors in reaching a decision.

SECTION 3 — MEDICAL INFORMATION AUTHORIZATION

MEDICAL PROFESSIONAL, HOSPITAL, OR MEDICAL FACILITY (NAME AND ADDRESS)

DATE	MEDICAL RECORD/PATIENT FILE NO.

I hereby authorize my medical professional or hospital to answer any questions from the DMV, or its employees, relating to my physical or mental condition, and/or drug and/or alcohol use, and to release any related information or records to the DMV or its employees. Any expense involved is to be charged to me and not to the DMV.

I hereby authorize the DMV to receive any information relating to my physical or mental condition, and/or drug and/or alcohol use or abuse, and to use the same in determining whether I have the ability to operate a motor vehicle safely.

NOTE: You may wish to make a copy of the completed Driver Medical Evaluation for your records.

SIGNED

DATE

DS 326 (REV. 6/2020) WWW

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SECTIONS 5 -13 TO BE COMPLETED BY PHYSICIAN, PHYSICIAN’S ASSISTANT OR ADVANCED PRACTICE REGISTERED NURSE

SECTION 4 — MEDICAL PROFESSIONAL’S MEDICAL EVALUATION INSTRUCTIONS

INSTRUCTIONS TO THE MEDICAL PROFESSIONAL (MP): The DMV records indicate your patient may have a condition that could affect the safe operation of a motor vehicle. (See Instructions to the Medical Professional, page 1 for the specific medical condition that is a concern to the department.) With your assistance, the department hopes to resolve the matter with a minimum of inconvenience to all concerned.

The Health History and Medical Information Authorization sections on page 1 must be completed and signed by the patient before you complete this Driver Medical Evaluation form.

Your experience and knowledge of the patient’s condition, results of medical examinations and treatment plans, will be of great value in assisting the department to determine a proper licensing decision. PLEASE ANSWER ALL QUESTIONS on this form. If questions do not apply, indicate “N/A”. You may furnish a narrative report if you prefer, but please include all information pertinent to your patient. The department has sole responsibility for any decision regarding the patient’s driving qualifications and licensure. The department will also consider non-medical factors in reaching a decision.

SECTION 5 — VISION

VISUAL ACUITY (without bioptic telescope)	BOTH EYES	RIGHT EYE		LEFT EYE
Without Lenses	20/	20/		20/
With Present Lenses	20/	20/		20/
ANY EYE INJURY OR DISEASE? (LIST)		IS FURTHER EYE EXAMINATION SUGGESTED?
		Yes	No

SECTION 6 — TREATMENT BY OTHER MEDICAL PROFESSIONAL(S)

IS THIS PATIENT BEING TREATED FOR ANY CONDITION BY ANOTHER MP?

Yes No

IF YES, PLEASE INDICATE NAME OF TREATING MP(S)

CONDITION BEING TREATED

SECTION 7 — TREATMENT UNDER YOUR SUPERVISION

DIAGNOSIS (IF THE DIAGNOSIS IS A DISORDER CHARACTERIZED BY LAPSES OF CONSCIOUSNESS, DEMENTIA, OR DIABETES, COMPLETE PAGE 3,4 OR 5.)

DO YOU NEED TO SEE YOUR PATIENT AT REGULAR INTERVALS? IF YES, HOW OFTEN?

Yes	No

PROGNOSIS

IS THE CONDITION					(IF MULTIPLE CONDITIONS, PLEASE DESCRIBE STATUS AND PROGNOSIS IN
Improving		Stable	Worsening or deteriorating	Subject to change
Improving		Stable	Worsening or deteriorating	Subject to change	COMMENTS BELOW.)
MANIFESTATIONS (SYMPTOMS):

(PRESENT)

(PAST)							MAY CONDITION IMPAIR VISION?
							Yes	No

HOW LONG HAS THIS PERSON BEEN YOUR PATIENT?					DATE OF LAST EXAMINATION

IS YOUR PATIENT UNDER A CONTROLLED MEDICAL PROGRAM?					HOW LONG HAS CONTROL BEEN MAINTAINED?
Yes	No

IS THE PATIENT ADHERING TO THE MEDICAL REGIMEN?					IS THE PATIENT KNOWLEDGEABLE ABOUT THE MEDICAL CONDITION?
Yes	No	If no, please explain:			Yes	No

LIST THE MEDICATIONS PRESCRIBED. PLEASE INCLUDE DOSAGE AND FREQUENCY OF USE


WHEN WAS THE LAST MEDICATION CHANGE MADE?

WOULD THE SIDE EFFECTS FROM THE PRESCRIBED MEDICATIONS INTERFERE WITH YOUR PATIENT’S ABILITY TO DRIVE SAFELY?
Yes	No	If yes, please describe:

DOES YOUR PATIENT’S MEDICAL CONDITION CURRENTLY AFFECT SAFE DRIVING?
Yes	No	If yes, please explain:

DO YOU CURRENTLY ADVISE AGAINST DRIVING?					WOULD YOU RECOMMEND A DRIVING TEST BE GIVEN BY DMV?
Yes	No				Yes	No

MP COMMENTS:

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DS 326 (REV. 6/2020) WWW

SECTION 8 — LEVELS OF FUNCTIONAL IMPAIRMENTS

Functional impairments that may affect safe driving ability. Please check where applicable.

MILD MODERATE SEVERE

Visual neglect	.........................................
Left side	Right side

Loss of upper extremity motor control ....

Left side

Right side

Loss of lower extremity motor control.....

Left side

Right side

WOULD ADAPTIVE DEVICES AID YOUR PATIENT IN COMPENSATING FOR THEIR DISABILITY AS IT PERTAINS TO SAFE DRIVING?

Yes No

Uncertain

IF YES, PLEASE DESCRIBE

SECTION 9 — DEMENTIA OR COGNITIVE IMPAIRMENTS

Alzheimer’s Disease

Other Dementia (Please describe the type of dementia below, e.g., multi-infarct, metabolic, post-traumatic.)

HISTORY OF DISEASE, RESULTS OF TESTING, ETC.

Using the definitions given below, please rate the severity of the following forms of cognitive impairments in this patient.

Mild:	Judgment is relatively intact but work or social activities are significantly impaired. Ability to safely operate a motor vehicle may
	or may not be impaired.

Moderate: Independent living is hazardous and some degree of supervision is necessary. The individual is unable to cope with the environment and driving would be dangerous.

Severe:	Activities of daily living are so impaired that continual supervision is required. This person is incapable of driving a motor vehicle.
	NONE	MILD MODERATE SEVERE UNCERTAIN

Memory Loss ...................................

Depression, secondary to dementia

Diminished Judgment ......................

Impaired Attention............................

Impaired Language Skills ................

Impaired Visual Spatial Skills ..........

Impulsive Behavior ..........................

Problem Solving Deficits..................

Loss of Awareness of Disability .......

OVERALL DEGREE OF IMPAIRMENT

DS 326 (REV. 6/2020) WWW

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SECTION 10 — LAPSE OF CONSCIOUSNESS DISORDER

PLEASE IDENTIFY THE LAPSE OF CONSCIOUSNESS DISORDER BEING REPORTED (Type of seizure, nocturnal, isolated,syncope, blackouts,		DATE(S) OF EPISODE(S) IN THE PAST THREE YEARS
etc.)

DATE OF ONSET, IF KNOWN	DATE AND TIME OF LAST EPISODE

Please indicate the impairments identified below that are presently shown by your patient.

YES

UNCERTAIN

Sporadic loss of conscious awareness.......................................................................................

Loss of consciousness ...............................................................................................................

Impaired motor function..............................................................................................................

EFFECTS AFTER EPISODE

Confusion ...................................................................................................................................

Diminished concentration ...........................................................................................................

Diminished judgment ..................................................................................................................

Memory loss ...............................................................................................................................

If medication is taken to control seizures, are the serum levels recorded?................................

Are the serum levels medically acceptable? ..............................................................................

COMMENT

SECTION 11 — DIABETES

PLEASE INDICATE THE TYPE OF DIABETES THIS PATIENT HAS				DATE OF DIAGNOSIS
Type I	Type 2	Gestational

WHAT METHOD OF TREATMENT IS REQUIRED?
Controlled diet		Oral diabetes medication	Insulin injections		Insulin pump	Other:

HAS THIS PATIENT RECEIVED DIABETES EDUCATION FROM A HEALTH CARE TEAM?

Yes No

DOES THIS PATIENT COMPLY WITH THE PRESCRIBED TREATMENT PLAN?

Yes No

IF NO, PLEASE EXPLAIN

IS THE DIABETES MANAGED AT THIS TIME?
Yes	No

IF YES, HOW LONG HAS DIABETES BEEN MANAGED OR MAINTAINED?			IF NO, PLEASE EXPLAIN

WHAT ARE THIS PATIENT’S FASTING BLOOD GLUCOSE LEVELS?			AFTER HOW MANY HOURS OF FASTING?

WITHIN THE LAST THREE YEARS, HAS THIS PATIENT EXPERIENCED			REASON FOR EPISODES (e.g., non-compliance w/regimen, change in condition, insulin unavailable, illness, etc.)
Hypoglycemic episodes?		Hyperglycemic episodes?

Please indicate the complications manifested by the hypoglycemic or hyperglycemic episodes and rate the severity of each.

NONE

MILD

MODERATE SEVERE UNCERTAIN

Abdominal pain................................

Cognitive deficits .............................

Confusion ........................................

Disorientation...................................

Incoordination..................................

Hypoglycemic unawareness............

Lack of stamina ...............................

Loss of consciousness ....................

Stupor ..............................................

Visual changes ................................

Ketoacidosis ....................................

Slowed reactions .............................

Seizures...........................................

Weakness or fatigue........................

Other................................................

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DS 326 (REV. 6/2020) WWW

DOES THIS PATIENT MANAGE HYPOGLYCEMIC OR HYPERGLYCEMIC EPISODES?
Yes	No	If no, please explain:

HAS THIS PATIENT’S DIABETES CAUSED ANY OF THE FOLLOWING CHRONIC COMPLICATIONS?
Visual changes		Kidney disease	Nervous system disease	Vascular disease

PLEASE DESCRIBE THE EXTENT OF THE COMPLICATIONS

HAS THE PATIENT BEEN HOSPITALIZED WITHIN THE LAST THREE YEARS DUE TO DIABETES COMPLICATIONS?		WHAT COMPLICATIONS NECESSITATED
Yes	No If yes, please give dates:	HOSPITALIZATION?

HAS AMPUTATION BEEN NECESSARY?

Yes No

IF YES, PLEASE EXPLAIN

SECTION 12 — ADDITIONAL COMMENTS BY MEDICAL PROFESSIONAL CONCERNING ANY CONDITION AFFECTING SAFE DRIVING

SECTION 13 — MEDICAL PROFESSIONAL’S SIGNATURE

MP’S SIGNATURE	MP’S NAME (PRINTED)	DATE
X
CLASSIFICATION OR SPECIALTY	MEDICAL LICENSE NUMBER	TELEPHONE NUMBER
		(	)

DS 326 (REV. 6/2020) WWW

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Step 2: Right now, you can begin editing the form ds 326. Our multifunctional toolbar is available to you - add, remove, adjust, highlight, and conduct several other commands with the words and phrases in the form.

Prepare the following parts to complete the file:

Remember to fill up the I certify or declare under penalty, DRIVERS SIGNATURE X, SECTION DRIVERS ADVISORY, All records of the DMV relating to, The department has sole, SECTION MEDICAL INFORMATION, DATE, MEDICAL RECORDPATIENT FILE NO, I hereby authorize my medical, I hereby authorize the DMV to, NOTE You may wish to make a copy, DATE, DS REV WWW, and Page of box with the expected details.

The application will require data to automatically fill up the field SECTION VISION VISUAL ACUITY, With Present Lenses ANY EYE INJURY, BOTH EYES, SECTION TREATMENT BY OTHER, Yes, IF YES PLEASE INDICATE NAME OF, CONDITION BEING TREATED, RIGHT EYE, LEFT EYE, IS FURTHER EYE EXAMINATION, Yes, SECTION TREATMENT UNDER YOUR, DO YOU NEED TO SEE YOUR PATIENT AT, Yes PROGNOSIS, and IS THE CONDITION.

step 3 to entering details in dmv ds 326

The PAST, MAY CONDITION IMPAIR VISION, Yes, HOW LONG HAS THIS PERSON BEEN YOUR, DATE OF LAST EXAMINATION, IS YOUR PATIENT UNDER A CONTROLLED, HOW LONG HAS CONTROL BEEN, Yes, IS THE PATIENT ADHERING TO THE, Yes, If no please explain, LIST THE MEDICATIONS PRESCRIBED, IS THE PATIENT KNOWLEDGEABLE ABOUT, Yes, and WHEN WAS THE LAST MEDICATION segment can be used to indicate the rights and responsibilities of either side.

Finish by reading these sections and filling out the proper information: Functional impairments that may, MILD MODERATE SEVERE, Visual neglect, Left side, Right side, Loss of upper extremity motor, Left side, Right side, Loss of lower extremity motor, Left side, Right side, WOULD ADAPTIVE DEVICES AID YOUR, Yes, Uncertain, and IF YES PLEASE DESCRIBE.

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