Section 28.23 - Health Questionnaire(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.Cal. Code Regs. Tit. 13, § 28.23
1. New section filed 9-12-2000; operative 10-12-2000 (Register 2000, No. 37).
2. Amendment of subsections (a) and (b)(2)(M) filed 10-18-2005; operative 11-17-2005 (Register 2005, No. 42).
3. Change without regulatory effect amending subsection (a) and NOTE filed 6-19-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 25). Note: Authority cited: Section 1651, Vehicle Code. Reference: Sections 12804.2, 12804.12 and 12804.14, Vehicle Code.
1. New section filed 9-12-2000; operative 10-12-2000 (Register 2000, No. 37).
2. Amendment of subsections (a) and (b)(2)(M) filed 10-18-2005; operative 11-17-2005 (Register 2005, No. 42).
3. Change without regulatory effect amending subsection (a) and Note filed 6-19-2014 pursuant to section 100, title 1, California Code of Regulations (Register 2014, No. 25).