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Get ds 326 2020-2024

NOTE You may wish to make a copy of the completed Driver Medical Evaluation for your records. SIGNED DS 326 REV. O. Box 934345 MS J-234 Sacramento CA 95818 A Public Service Agency DRIVER MEDICAL EVALUATION Medical information is CONFIDENTIAL under Section 1808. 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. 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. STATE OF CALIFORNIA PHYSICIAN RETURN FORM TO DEPARTMENT OF MOTOR VEHICLES Licensing Operations Division Driver Safety Branch P. PLEASE PRINT LEGIBLY. 2 through 5. The Department of Motor Vehicles 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 RETURN BY 1. DRIVER INFORMATION NAME LAST FIRST MIDDLE STREET ADDRESS DRIVER LICENSE NO. BIRTH DATE CITY ZIP FIELD FILE PATIENT S DAYTIME OR HOME PHONE NO. DRIVER MUST COMPLETE HEALTH HISTORY BELOW* Please explain any YES answers 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 2. DRIVER S ADVISORY STATEMENT for refusal to issue a license or to withdraw the driving privilege. All records of the Department of Motor Vehicles relating to the physical or mental condition of any person are confidential and not open to public inspection California Vehicle Code Section 1808.

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