*DS326* � Ы���� ͻ����� ߹���� PHYSICIAN RETURN FORM TO: DRIVER MEDICAL EVALUATION (Medical information is CONFIDENTIAL under California Vehicle Code �1808.5 CVC) DEPARTMENT OF MOTOR VEHICLES Licensing Operations Division Driver Safety Branch P. O. Box 934345 MS J-234 Sacramento, CA 95818 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: SECTION 1 -- DRIVER INFORMATION NAME (LAST, FIRST, MIDDLE) DRIVER LICENSE NO. BIRTH DATE FIELD FILE RETURN BY: 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 Seizure, convulsions, or epilepsy Dizziness, fainting, or frequent headaches Eye problem (except corrective lenses) Cardiovascular (heart or blood vessel) disease Heart attack, stroke, or paralysis Lung disease (include tuberculosis, asthma or emphysema) Nervous stomach, ulcer, or digestive problems Diabetes or high blood sugar Kidney disease, stones, blood in urine, or dialysis Muscular disease Any permanent impairment Nervous or psychiatric disorder Regular or frequent alcohol use Problems with the use of alcohol or drugs Other disorders or diseases Any major illness, injury, or operations in last 5 years 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 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. non-medical factors in reaching a decision. SECTION 3 -- MEDICAL INFORMATION AUTHORIZATION MEDICAL PROFESSIONAL, HOSPITAL, OR MEDICAL FACILITY (NAME AND ADDRESS) DATE I hereby authorize my medical professional or hospital to answer any questions from the DMV, or its employees, relating to my physical or involved is to be charged to me and not to the DMV. I hereby authorize 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 X �� ��� ����� ������� ��� п�� � �� � American LegalNet, Inc. www.FormsWorkFlow.com 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 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 in reaching a decision. SECTION 5 -- VISION VISUAL ACUITY (without bioptic telescope) Without Lenses With Present Lenses ANY EYE INJURY OR DISEASE? (LIST) BOTH EYES RIGHT EYE LEFT EYE IS FURTHER EYE EXAMINATION SUGGESTED? Yes SECTION 6 -- TREATMENT BY OTHER MEDICAL PROFESSIONAL(S) IS THIS PATIENT BEING TREATED FOR ANY CONDITION BY ANOTHER MP? 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 PROGNOSIS No IS THE CONDITION Improving Stable Worsening or deteriorating Subject to change (IF MULTIPLE CONDITIONS, PLEASE DESCRIBE STATUS AND PROGNOSIS IN COMMENTS BELOW.) MANIFESTATIONS (SYMPTOMS): (PRESENT) (PAST) MAY CONDITION IMPAIR VISION? Yes HOW LONG HAS THIS PERSON BEEN YOUR PATIENT? DATE OF LAST EXAMINATION No IS YOUR PATIENT UNDER A CONTROLLED MEDICAL PROGRAM? HOW LONG HAS CONTROL BEEN MAINTAINED? Yes Yes No IS THE PATIENT KNOWLEDGEABLE ABOUT THE MEDICAL CONDITION? IS THE PATIENT ADHERING TO THE MEDICAL REGIMEN? 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 Yes Yes MP COMMENTS: No If yes, please describe: No If yes, please explain: WOULD YOU RECOMMEND A DRIVING TEST BE GIVEN BY DMV? DOES YOUR PATIENT'S MEDICAL CONDITION CURRENTLY AFFECT SAFE DRIVING? DO YOU CURRENTLY ADVISE AGAINST DRIVING? No Yes No п�� � �� � �� ��� ����� ������� ��� American LegalNet, Inc. www.FormsWorkFlow.com 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 Yes No Uncertain IF YES, PLEASE DESCRIBE SECTION 9 -- DEMENTIA OR COGNITIVE IMPAIRMENTS Alzheimer's Disease Other Dementia HISTORY OF DISEASE, RESULTS OF TESTING, ETC. or may not be impaired. Moderate: Independent living is hazardous and some degree of supervision is necessary. The individ