California Code of Regulations › Title 13 - Motor Vehicles › Division 1 - Department of Motor Vehicles › Chapter 1 - Department of Motor Vehicles › Article 2.1 - Commercial Driver Licenses › Section 28.23 - Health Questionnaire

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
(a) The Health Questionnaire, form DL 546
				  (Rev. 11/2004), shall be submitted upon application for a hazardous
				  agricultural materials endorsement or a restricted Class A driver license and
				  every two years thereafter.
(b) The
				  Health Questionnaire shall contain the following information:
(1) The applicant's true full name, address,
				  date of birth, driver license number, and daytime telephone number.
(2) A "yes" or "no" response as to whether
				  the applicant:
(A) has difficulty recognizing
				  the colors of red, green, and amber used in traffic signal lights and
				  devices.
(B) has peripheral vision
				  of less than 70 degrees for either eye.
(C) has difficulty perceiving a forced
				  whispered voice in the better ear, without a hearing aid, at not less than five
				  (5) feet.
(D) has a vision
				  impairment in either eye that is not correctable to visual acuity of 20/40 or
				  better.
(E) has a missing foot,
				  leg, hand, finger, or arm.
(F) has
				  an impairment of a hand or finger.
(G) has any other impairment of an arm, hand,
				  foot, or leg, or any other limitation.
(H) has diabetes requiring insulin for
				  control.
(I) has had a hypoglycemic
				  episode in the last three (3) years.
(J) has had any other adverse reaction
				  related to diabetes in the last three (3) years.
(K) has had a heart attack, angina, coronary
				  insufficiency, thrombosis, stroke, or other heart problem, or cardiovascular
				  disease, and if "yes," whether the applicant has had labored breathing,
				  fainting, collapse, congestive heart failure, or other symptoms in the last
				  three (3) years.
(L) has been
				  diagnosed with a respiratory condition, such as emphysema, chronic asthma, or
				  tuberculosis and, if "yes," whether the respiratory condition is likely to
				  interfere with the applicant's ability to drive a motor vehicle
				  safely.
(M) has been diagnosed with
				  high blood pressure, and if "yes," whether the applicant's blood pressure is
				  usually 140/90 or higher.
(N) has
				  never been diagnosed with a rheumatic, arthritic, orthopedic, muscular,
				  neuromuscular, or vascular disease, and if "yes," whether the condition is
				  likely to interfere with the applicant's ability to drive a motor vehicle
				  safely.
(O) has ever been diagnosed
				  with any mental, nervous, organic, or functional disease, or psychiatric
				  disorder and, if "yes," whether the condition is likely to interfere with the
				  applicant's ability to drive a motor vehicle safely.
(P) has ever been diagnosed with epilepsy or
				  any other condition which may cause loss of consciousness or loss of control,
				  and if "yes," whether the applicant has had a loss of consciousness or loss of
				  control in the last three (3) years.
(Q) uses a controlled substance, amphetamine,
				  narcotic, or any other habit-forming drug, and if "yes," whether the
				  applicant's physician prescribed the drug and whether the applicant's physician
				  advised the applicant not to drive when taking the drug.
(R) has a current clinical diagnosis of
				  alcoholism, and if "yes," when the applicant last had an alcoholic
				  beverage.
(3) An
				  explanation of any "yes" answer.
(4) The physician's name, office address, and
				  telephone number.
(5) The month and
				  year of the applicant's last visit to the physician.
(6) A certification, signed and dated by the
				  applicant under penalty of perjury, that the information provided is true and
				  correct, and that the applicant consents to the release of medical information
				  to the department by the physician named on the form.