Form DS 326 is an important document for those looking to sponsor a foreign national. The form helps sponsors provide the required information to petition for their relative's immigration status. It is important to complete the form accurately and thoroughly, as any mistakes could delay the process. There are many helpful tips available online that can guide you through the process of completing Form DS 326. Sponsors should be prepared to provide detailed information about their relative, including their educational and employment history. Completing this form takes some effort but it is well worth it in order to help your loved one come join you in the United States.
Below is the information concerning the file you were in search of to fill out. It can show you how much time it will take to finish form ds 326, exactly what parts you will have to fill in, and so on.
Question | Answer |
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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, california driver medical, ds326, form driver medical evaluation |
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*DS326* |
A Public Service Agency |
DRIVER MEDICAL EVALUATION |
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(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
INSTRUCTIONS TO THE MEDICAL PROFESSIONAL: Please complete Sections
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:
PHYSICIAN RETURN FORM TO:
RETURN BY:
FAX NUMBER:
SECTION 1 — DRIVER INFORMATION
NAME (LAST, FIRST, MIDDLE) |
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DRIVER LICENSE NO. |
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BIRTH DATE |
FIELD FILE |
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STREET ADDRESS |
CITY |
ZIP |
PATIENT’S DAYTIME OR HOME PHONE NO. |
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DRIVER MUST COMPLETE HEALTH HISTORY BELOW. (Please explain any “YES” answers)
YES |
NO |
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NO |
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Head, neck, spinal injury, disorders or illnesses |
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Kidney disease, stones, blood in urine, or dialysis |
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Seizure, convulsions, or epilepsy |
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Muscular disease |
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Dizziness, fainting, or frequent headaches |
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Any permanent impairment |
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Eye problem (except corrective lenses) |
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Nervous or psychiatric disorder |
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Cardiovascular (heart or blood vessel) disease |
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Regular or frequent alcohol use |
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Heart attack, stroke, or paralysis |
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Problems with the use of alcohol or drugs |
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Lung disease (include tuberculosis, asthma or emphysema) |
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Other disorders or diseases |
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Nervous stomach, ulcer, or digestive problems |
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Any major illness, injury, or operations in last 5 years |
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Diabetes or high blood sugar |
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Currently taking medications |
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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
X
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
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
X
DATE
DS 326 (REV. 6/2020) WWW |
Page 1 of 5 |
SECTIONS 5
SECTION 5 — VISION
VISUAL ACUITY (without bioptic telescope) |
BOTH EYES |
RIGHT EYE |
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LEFT EYE |
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Without Lenses |
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20/ |
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20/ |
With Present Lenses |
20/ |
20/ |
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ANY EYE INJURY OR DISEASE? (LIST) |
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IS FURTHER EYE EXAMINATION SUGGESTED? |
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Yes |
No |
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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 |
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PROGNOSIS |
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IS THE CONDITION |
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(IF MULTIPLE CONDITIONS, PLEASE DESCRIBE STATUS AND PROGNOSIS IN |
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Improving |
Stable |
Worsening or deteriorating |
Subject to change COMMENTS BELOW.) |
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MANIFESTATIONS (SYMPTOMS): |
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(PRESENT) |
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(PAST) |
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MAY CONDITION IMPAIR VISION? |
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Yes |
No |
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HOW LONG HAS THIS PERSON BEEN YOUR PATIENT? |
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DATE OF LAST EXAMINATION |
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IS YOUR PATIENT UNDER A CONTROLLED MEDICAL PROGRAM? |
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HOW LONG HAS CONTROL BEEN MAINTAINED? |
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No |
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IS THE PATIENT ADHERING TO THE MEDICAL REGIMEN? |
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IS THE PATIENT KNOWLEDGEABLE ABOUT THE MEDICAL CONDITION? |
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Yes |
No |
If no, please explain: |
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Yes |
No |
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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?
Yes No
WOULD YOU RECOMMEND A DRIVING TEST BE GIVEN BY DMV?
Yes No
MP COMMENTS:
Page 2 of 5 |
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 |
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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.,
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 |
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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. |
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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 |
Page 3 of 5 |
SECTION 10 — LAPSE OF CONSCIOUSNESS DISORDER
PLEASE IDENTIFY THE LAPSE OF CONSCIOUSNESS DISORDER BEING REPORTED (Type of seizure, nocturnal, isolated,syncope, blackouts, etc.)
DATE(S) OF EPISODE(S) IN THE PAST THREE YEARS
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 |
NO |
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
Type I |
Type 2 |
Gestational |
DATE OF DIAGNOSIS
WHAT METHOD OF TREATMENT IS REQUIRED? |
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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? |
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Yes |
No |
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IF YES, HOW LONG HAS DIABETES BEEN MANAGED OR MAINTAINED? |
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IF NO, PLEASE EXPLAIN |
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WHAT ARE THIS PATIENT’S FASTING BLOOD GLUCOSE LEVELS? |
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AFTER HOW MANY HOURS OF FASTING? |
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WITHIN THE LAST THREE YEARS, HAS THIS PATIENT EXPERIENCED |
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REASON FOR EPISODES (e.g., |
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Hypoglycemic episodes? |
Hyperglycemicepisodes? |
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Please indicate the complications manifested by the hypoglycemic or hyperglycemic episodes and rate the severity of each. |
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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................................................
Page 4 of 5 |
DS 326 (REV. 6/2020) WWW |
DOES THIS PATIENT MANAGE HYPOGLYCEMIC OR HYPERGLYCEMIC EPISODES? |
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Yes |
No |
If no, please explain: |
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HAS THIS PATIENT’S DIABETES CAUSED ANY OF THE FOLLOWING CHRONIC COMPLICATIONS? |
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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 |
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Yes |
No If yes, please give dates: |
HOSPITALIZATION? |
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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 |
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X |
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CLASSIFICATION OR SPECIALTY |
MEDICAL LICENSE NUMBER |
TELEPHONE NUMBER |
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( |
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DS 326 (REV. 6/2020) WWW |
Page 5 of 5 |