The DS 326 form, also known as the Driver Medical Evaluation, is a document required by the California Department of Motor Vehicles (DMV) to assess an individual's medical fitness to drive. This form gathers essential health information from both the driver and their medical professional, ensuring that any conditions affecting safe driving are properly evaluated. If you need to fill out this important form, please click the button below.
The DS 326 form, known as the Driver Medical Evaluation, serves an essential role in ensuring public safety on the roads. This form is primarily designed for individuals whose medical conditions may impact their ability to operate a vehicle safely. It requires drivers to provide personal information and a comprehensive health history, including any existing medical conditions, medications, and relevant past injuries. After completing the initial sections, the driver must take the form to a medical professional who will evaluate their health and provide insights into how their condition may affect driving capabilities. The medical professional is tasked with filling out additional sections that delve into the specifics of the driver's health status, including vision, cognitive function, and any impairments that could hinder safe driving. The confidentiality of the medical information is strictly maintained under California law, reassuring individuals that their private health details will not be publicly disclosed. This form not only aids the Department of Motor Vehicles in making informed licensing decisions but also emphasizes the importance of health in the context of driving. By fostering a collaborative approach between drivers and healthcare providers, the DS 326 form aims to promote safe driving practices and protect the well-being of all road users.
*DS326*
A Public Service Agency
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:
RETURN BY:
PHYSICIAN RETURN FORM TO:
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
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
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 non-medical factors in reaching a decision.
SECTION 3 — MEDICAL INFORMATION AUTHORIZATION
MEDICAL PROFESSIONAL, HOSPITAL, OR MEDICAL FACILITY (NAME AND ADDRESS)
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
DS 326 (REV. 6/2020) WWW
Page 1 of 5
Print
Clear Form
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 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.
SECTION 5 — VISION
VISUAL ACUITY (without bioptic telescope)
BOTH EYES
RIGHT EYE
LEFT EYE
Without Lenses
20/
With Present Lenses
ANY EYE INJURY OR DISEASE? (LIST)
IS FURTHER EYE EXAMINATION SUGGESTED?
Yes
No
SECTION 6 — TREATMENT BY OTHER MEDICAL PROFESSIONAL(S)
IS THIS PATIENT BEING TREATED FOR ANY CONDITION BY ANOTHER MP?
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?
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?
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?
IS THE PATIENT ADHERING TO THE MEDICAL REGIMEN?
IS THE PATIENT KNOWLEDGEABLE ABOUT THE MEDICAL CONDITION?
If no, please explain:
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?
If yes, please describe:
DOES YOUR PATIENT’S MEDICAL CONDITION CURRENTLY AFFECT SAFE DRIVING?
If yes, please explain:
DO YOU CURRENTLY ADVISE AGAINST DRIVING?
WOULD YOU RECOMMEND A DRIVING TEST BE GIVEN BY DMV?
MP COMMENTS:
Page 2 of 5
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 ....
Loss of lower extremity motor control.....
WOULD ADAPTIVE DEVICES AID YOUR PATIENT IN COMPENSATING FOR THEIR DISABILITY AS IT PERTAINS TO SAFE DRIVING?
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
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,
DATE(S) OF EPISODE(S) IN THE PAST THREE YEARS
etc.)
DATE OF ONSET, IF KNOWN
DATE AND TIME OF LAST EPISODE
Please indicate the impairments identified below that are presently shown by your patient.
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
DATE OF DIAGNOSIS
Type I
Type 2
Gestational
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?
DOES THIS PATIENT COMPLY WITH THE PRESCRIBED TREATMENT PLAN?
IF NO, PLEASE EXPLAIN
IS THE DIABETES MANAGED AT THIS TIME?
IF YES, HOW LONG HAS DIABETES BEEN MANAGED OR MAINTAINED?
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?
Hyperglycemic episodes?
Please indicate the complications manifested by the hypoglycemic or hyperglycemic episodes and rate the severity of each.
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
DOES THIS PATIENT MANAGE HYPOGLYCEMIC OR HYPERGLYCEMIC EPISODES?
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
No If yes, please give dates:
HOSPITALIZATION?
HAS AMPUTATION BEEN NECESSARY?
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)
CLASSIFICATION OR SPECIALTY
MEDICAL LICENSE NUMBER
TELEPHONE NUMBER
(
)
Page 5 of 5
Filling out the DS 326 form requires attention to detail and accuracy. This form must be completed by the driver and a medical professional. After the driver fills out the necessary sections, they will need to provide the form to their medical professional for further evaluation. It is important to ensure that all information is clear and legible.
What is the purpose of the DS 326 form?
The DS 326 form is a Driver Medical Evaluation used by the California Department of Motor Vehicles (DMV). Its main purpose is to gather medical information about a driver's health. This information helps the DMV determine if a driver can safely operate a motor vehicle. The form must be completed by the driver and their medical professional.
Who should complete the DS 326 form?
The driver must complete Sections 1-3 of the form. This includes providing personal information and answering health-related questions. After the driver has completed their part, a medical professional must fill out Sections 5-13. This professional should be someone familiar with the driver's health history and current medical condition.
What kind of medical conditions does the DS 326 form address?
The form addresses a variety of medical conditions that could affect driving ability. These include:
Drivers are asked to disclose any conditions that may impair their ability to drive safely.
Is the information on the DS 326 form confidential?
Yes, the information provided on the DS 326 form is confidential. Under California Vehicle Code §1808.5, medical information is protected and not open to public inspection. The DMV will only share this information with authorized individuals, such as the driver or their representative, upon receiving signed consent.
What happens if a driver does not submit the DS 326 form?
If a driver fails to submit the DS 326 form, the DMV may refuse to issue a driver's license or may withdraw the driver's existing driving privileges. Providing the requested medical information is essential for the DMV to make informed decisions about a driver's qualifications.
Can a driver keep a copy of the completed DS 326 form?
Yes, it is advisable for drivers to make a copy of the completed DS 326 form for their records. Keeping a copy can help in case there are any questions or issues regarding the submitted information in the future.
Completing the DS 326 form accurately is essential for ensuring that the Department of Motor Vehicles (DMV) can assess a driver's medical fitness to operate a vehicle. However, individuals often make mistakes when filling out this form, which can lead to delays or complications in the licensing process.
One common mistake is failing to print legibly. The form specifically instructs drivers to print legibly, yet many individuals do not adhere to this guideline. Illegible handwriting can result in misunderstandings or misinterpretations of the provided information.
Another frequent error involves incomplete health history sections. Drivers may neglect to answer all health questions, particularly those that require detailed explanations for "YES" responses. Omitting critical information can prevent the DMV from making an informed decision regarding driving qualifications.
Some individuals may also forget to sign and date the form. The signature serves as a certification that the information is true and correct. Without a signature, the form may be considered invalid, leading to further complications.
Inaccurate personal information is another mistake that occurs. Drivers sometimes provide incorrect details, such as their name, driver license number, or birth date. These discrepancies can create confusion and may delay the processing of the form.
Additionally, some drivers do not provide complete contact information, including a daytime or home phone number. This omission can hinder communication between the DMV and the driver, especially if further clarification is needed.
Failure to include information about current medications is also a common issue. It is crucial for drivers to list all medications, including dosages and frequency. Incomplete medication information may lead to an inaccurate assessment of the driver's health status.
Some individuals overlook the requirement to provide additional explanations for specific health conditions. If a driver answers "YES" to any health question, they must provide details about the condition, including onset date and treatment. Neglecting this step can result in an incomplete evaluation.
Drivers may also misunderstand the importance of the medical professional's section. Some individuals fail to ensure that their healthcare provider completes this section thoroughly. The DMV relies on this information to evaluate the driver's medical condition effectively.
Another common mistake is not making a copy of the completed form for personal records. Keeping a copy can be beneficial for future reference or in case any issues arise during the processing of the form.
Lastly, individuals may not adhere to the submission instructions. Some may send the form to the wrong address or fail to follow the specified submission method, such as faxing. Ensuring that the form is sent correctly is crucial for timely processing.
The DS 326 form, known as the Driver Medical Evaluation, is a crucial document used by the Department of Motor Vehicles (DMV) to assess an individual's medical fitness to drive. Along with this form, there are several other documents that may be required or helpful in the evaluation process. Below are five common forms and documents often used in conjunction with the DS 326.
Each of these documents plays a significant role in ensuring that the DMV has a complete understanding of a driver's medical fitness. By providing thorough and accurate information, individuals can help facilitate the evaluation process and ensure that their driving privileges are assessed fairly.
The DS 326 form, which is a Driver Medical Evaluation, shares similarities with several other documents used in various contexts related to health assessments and driving qualifications. Below is a list of eight documents that are comparable to the DS 326 form, along with an explanation of how they are similar:
When filling out the DS 326 form, attention to detail is crucial. Here are eight essential do's and don'ts to ensure the process goes smoothly.
Misconceptions about the DS 326 Form
Here are key takeaways regarding the DS 326 form, which is used for Driver Medical Evaluation in California: