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Form Name	Form Ds 326
Form Length	5 pages
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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
	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:

PHYSICIAN RETURN FORM TO:

RETURN BY:

FAX NUMBER:

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

Page 1 of 5

SECTION 6 — TREATMENT BY OTHER MEDICAL PROFESSIONAL(S)

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

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.

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

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

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 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?

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	.........................................
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

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

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?
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?		Hyperglycemicepisodes?

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................................................

Page 4 of 5

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

Page 5 of 5

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