California DMV Driver Safety sends this five-page evaluation when its records show a driver may have a condition that could affect safe driving, naming that condition and a return-by date on page 1. The driver completes the health history and authorization, and the medical professional most familiar with the driver's health completes the medical sections. DMV uses it in reexaminations and medical probation.
The driver completes and signs Sections 1 to 3 (health history, advisory statement and medical information authorization) before handing it over. A physician, physician assistant or advanced practice registered nurse completes Sections 5 to 13, using the condition pages for dementia, lapses of consciousness or diabetes when they apply.
The driver fills in identifying details, answers a yes/no health history covering conditions such as seizures, diabetes, heart disease, stroke, eye problems and alcohol or drug use, explains each yes, and signs under penalty of perjury. Section 3 names your practice and authorizes you to release information to DMV. Section 4 says these must be completed and signed before you begin.
Record visual acuity without a bioptic telescope for both eyes, right and left, without lenses and with present lenses. List any eye injury or disease and answer whether further eye examination is suggested. This is a brief screen; the separate DL 62 is the vision specialist's report DMV uses when a driver fails its vision screening.
Answer whether another medical professional is treating the patient for any condition. If yes, give the name of each treating professional and the condition being treated. When a specialist manages the condition DMV named on page 1, listing that clinician here shows where the rest of the patient's care for it happens.
The core of the form: diagnosis, visit frequency, prognosis (improving, stable, worsening, subject to change), present and past symptoms, whether the condition may impair vision, how long the person has been your patient, date of last exam, control and adherence, medications with dose and frequency and last change, and whether the condition or medications affect safe driving. It ends asking whether you advise against driving and whether DMV should give a driving test.
Rate visual neglect and loss of upper and lower extremity motor control as mild, moderate or severe, and mark left or right side. Then answer whether adaptive devices would help the patient compensate for the disability as it pertains to safe driving (yes, no or uncertain), and describe them if yes.
Mark Alzheimer's disease or other dementia and describe the type, history and test results. Rate memory loss, depression secondary to dementia, judgment, attention, language, visual spatial skills, impulsive behavior, problem solving and loss of awareness of disability, plus overall degree, as none, mild, moderate, severe or uncertain. The form defines moderate as driving would be dangerous and severe as incapable of driving.
Identify the disorder (seizure type, nocturnal, isolated, syncope, blackouts), the dates of episodes in the past three years, onset date, and date and time of the last episode. Mark yes, no or uncertain for sporadic loss of awareness, loss of consciousness, impaired motor function, and after-effects such as confusion or memory loss, and whether seizure medication serum levels are recorded and acceptable.
Give the type and date of diagnosis, treatment (diet, oral medication, insulin injections, pump), diabetes education, compliance, whether it is managed and for how long, and fasting glucose levels. Report hypo- or hyperglycemic episodes in the last three years with their reasons and rate complications such as hypoglycemic unawareness or loss of consciousness, then chronic complications, hospitalizations and amputation.
Section 12 is for any further comment on conditions affecting safe driving. Section 13 is the medical professional's signature, printed name, date, classification or specialty, medical license number and phone. Section 4 notes that DMV has sole responsibility for the licensing decision and also weighs non-medical factors; Section 12 is where to add clinical context for that decision.
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Driver Medical Evaluation
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Sources for this guide
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Sections 4 to 13 are for a physician, physician assistant or advanced practice registered nurse. DMV asks the driver to take the form to the medical professional most familiar with their health history and current condition. Section 13 asks for the signature, printed name, classification or specialty, medical license number and phone.
The return-by date is printed on page 1, next to the condition DMV is concerned about and the Driver Safety office's return details. That office fills these in for the driver's case, so the date differs from one driver to the next. Check page 1 before the visit so the evaluation can be completed in time.
Yes. The form states that medical information is confidential under California Vehicle Code §1808.5, and DMV records about a person's physical or mental condition are not open to public inspection. The information used to decide driving qualifications is available to the driver or the driver's representative with signed authorization.
Section 7 directs you to the condition pages when the diagnosis involves lapses of consciousness, dementia or diabetes. Section 9 covers dementia or cognitive impairment on page 3, Section 10 covers lapse of consciousness disorders such as seizures or syncope on page 4, and Section 11 covers diabetes on pages 4 and 5.