The California DMV DL 546 form is a health questionnaire that applicants must complete to assess their medical qualifications for a driver's license. This form ensures that individuals can safely operate a vehicle by evaluating various health conditions that may impact driving ability. To get started on your application, fill out the form by clicking the button below.
The California DMV DL 546 form serves as an essential health questionnaire for individuals applying for or renewing their driver's licenses. This form is not intended for commercial licensing and must be completed by the applicant every two years. It includes a series of health-related questions designed to assess the applicant's ability to drive safely. Questions cover a range of medical conditions, including vision and hearing impairments, diabetes, cardiovascular issues, and mental health disorders. Each question requires a simple “yes” or “no” answer, with the opportunity to provide further explanation for any affirmative responses. If an applicant answers “yes” to certain questions, the DMV may reach out to their physician to verify medical qualifications before issuing a license. Completing the form accurately is crucial, as it ensures that individuals who may pose a risk on the road are identified and assessed appropriately. The form also emphasizes the importance of consulting with a physician if there is uncertainty about how to answer specific questions, reinforcing the connection between health and safe driving practices. Overall, the DL 546 form plays a vital role in maintaining road safety in California by ensuring that all drivers meet necessary health standards.
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
USE
dl 546 (rev.6/2011) WWW
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