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It instructs the driver to complete and sign Sections 1–3 and instructs medical professionals to complete Sections 5–13 on pages 2–5. 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Before giving this form to your medical professional, complete and sign Sections 1-3. PLEASE PRINT LEGIBLY.  \nINSTRUCTIONS 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:   \n\n| PHYSICIAN RETURN FORM TO: DEPARTMENT OF MOTOR VEHICLES\u003Cbr>Licensing Operations Division Driver Safety Branch\u003Cbr>P. O. Box 934345 MS J-234\u003Cbr>Sacramento, CA 95818 |\n| --- |\n| RETURN BY: |\n\nSECTION 1—DRIVER INFORMATION  \n\n| NAME (LAST, FIRST, MIDDLE) | DRIVER LICENSE NO. | BIRTH DATE | FIELD FILE |\n| --- | --- | --- | --- |\n| STREET ADDRESS CITY | ZIP | PATIENT’S DAYTIME OR HOME PHONE NO. |  |\n\nDRIVER MUST COMPLETE HEALTH HISTORY BELOW. (Please explain any “YES”answers)  \n\n| YES | NO |  | YES | NO |  |\n| --- | --- | --- | --- | --- | --- |\n|  |  | Head, neck, spinal injury, disorders or illnesses |  |  | Kidney disease, stones, blood in urine, or dialysis |\n|  |  | Seizure, convulsions, or epilepsy |  |  | Muscular disease |\n|  |  | Dizziness, fainting, or frequent headaches |  |  | Any permanent impairment |\n|  |  | Eye problem (except corrective lenses) |  |  | Nervous or psychiatric disorder |\n|  |  | Cardiovascular (heart or blood vessel) disease |  |  | Regular or frequent alcohol use |\n|  |  | Heart attack, stroke, or paralysis |  |  | Problems with the use of alcohol or drugs |\n|  |  | Lung disease (include tuberculosis, asthma or emphysema) |  |  | Other disorders or diseases |\n|  |  | Nervous stomach, ulcer, or digestive problems |  |  | Any major illness, injury, or operations in last 5 years |\n|  |  | Diabetes or high blood sugar |  |  | Currently taking medications |\n\nEXPLANATION: (Include onset date, diagnosis, medication, doctor’s name and address and any current condition or limitation. Attach additional sheet, if needed).  \n\n| 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. |  |\n| --- | --- |\n| DATE | DRIVER’S SIGNATURE\u003Cbr>X |\n| SECTION 2—DRIVER’S ADVISORY STATEMENT |  |\n| 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.\u003Cbr>All records ofthe 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. |  |\n| SECTION 3—MEDICAL INFORMATION AUTHORIZATION |  |\n\nMEDICAL PROFESSIONAL, HOSPITAL, OR MEDICAL FACILITY (NAME AND ADDRESS)  \n\n| DATE | MEDICAL RECORD/PATIENT FILE NO. |\n| --- | --- |\n\nI 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.  \nI hereby authorize the DMV to receive any information relating to my physical or mental condition, and/or drug and/or alc","cbCaiqB0SE5N8dNg","https://ap.wps.com/l/cbCaiqB0SE5N8dNg","pdf",280917,"English","# Driver Medical Evaluation (DS326)\n## Instructions to the Driver\n## Instructions to the Medical Professional\n## Section 1—Driver Information\n## Driver Health History Questions\n## Section 2—Driver’s Advisory Statement\n## Section 3—Medical Information Authorization\n## Section 4—Medical Professional’s Medical Evaluation Instructions\n## Section 5—Vision","[{\"question\":\"What does the DS326 form request from the driver?\",\"answer\":\"The driver completes and signs Sections 1–3. This includes driver identification and a health history set of YES/NO questions, along with required certifications and signature/date information.\"},{\"question\":\"What are the responsibilities of the medical professional?\",\"answer\":\"The medical professional completes Sections 5–13 on pages 2 through 5. The form requires answering all questions, indicating “N/A” when not applicable, and may include a narrative report if preferred.\"},{\"question\":\"How is medical information handled and authorized?\",\"answer\":\"The form explains that medical information is confidential under California Vehicle Code §1808.5 and includes an authorization section allowing the medical professional to answer DMV questions and release related records so the DMV can determine safe driving qualifications.\"}]","DS326 - Driver Medical Evaluation - Instructions | PDF",13]