(c) The medical form provided by the
department, shall be the Physician's Health Report, form DL 546A (NEW 12/2001),
and shall be completed and signed by a physician and 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
any other impairment of a hand, finger, arm, foot, or leg, or any other
limitation.
(G) has diabetes
requiring insulin for control.
(H)
has had a hypoglycemic episode or any other adverse reaction related to
diabetes in the last three (3) years.
(I) 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.
(J) 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.
(K) has ever been diagnosed
with high blood pressure of 160/90 or higher.
(L) has been diagnosed with 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.
(M) 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.
(N)
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.
(O) uses a controlled
substance, amphetamine, narcotic, or any other habit-forming drug, and if
"yes", whether the drug will interfere with the patient's ability to drive a
motor vehicle.
(P) has a history or
current clinical diagnosis of alcoholism.
(3) Visual acuity of each eye must be given
and be at least 20/40 in each eye with or without corrective lenses.
(A) Whether contact lenses are worn, and if
"yes", whether they are well adapted and tolerated.
(4) The applicant's blood pressure reading at
the time of the exam.
(5) An
explanation for any "yes" answers.
(6) A check-box indicating the applicant has
been examined and has no physical impairment or condition to preclude him or
her from driving a house car of more than 40 feet in length.
(7) The physician's name, office address,
telephone number, date of applicant's last visit, physician's medical license
or certificate number with the issuing state, date of the exam, and the
signature of the physician.
(8) 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 release of medical information to the department.