(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.
