Form Dld6a - Ut License Application Form Page 2
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1
2UT LICENSE #
UT ID #
Last Name
DOB
Examiner Notes and Completed Date Stamp:
Individuals who apply for or hold a license and have, or develop, or suspect that they have developed a physical, mental,
or emotional impairment that may affect driving safety are responsible for reporting this to the division or its agent.
DO YOU HAVE, OR HAVE YOU HAD, ANY OF THE FOLLOWING CONDITIONS IN THE LAST FIVE YEARS?
A
Diabetes
YES
NO
Diabetes (high blood sugar, sugar diabetes you control with diet, medication or insulin) or
hypoglycemia or other metabolic condition etc., which may interfere with driving safety?
YES
NO
B
Cardiovascular
Heart condition, with or without symptoms (heart attack, heart surgery, irregular rhythm, general heart
disease) within the last five years; or hypertension (high blood pressure) unable to be controlled with
medication?
YES
NO
C
Pulmonary
Pulmonary (lung) condition (asthma, emphysema, passing out from coughing, etc.) shortness of
breath which has required treatment?
YES
NO
Is an inhaler the only medication prescribed for this condition?
YES
NO
Are you required to use supplemental oxygen while driving?
D
Neurologic
YES
NO
Neurological condition (stroke, head injury, cerebral palsy, multiple sclerosis, muscular dystrophy,
Parkinson’s disease, etc.) which may interfere with driving safety?
E
Epilepsy
YES
NO
Seizures or other episodic conditions which include any recurrent loss of consciousness or control?
YES
NO
Commercial: Anytime during your life.
YES
NO
F
Learning and
Learning and memory difficulties which may interfere with driving safety?
Memory
YES
NO
G
Psychiatric
Psychological condition (severe anxiety, severe depression, severe behavioral mood conditions,
schizophrenia, etc.) or other conditions for which hospitalization has occurred or been recommended
by a physician or other mental health professional?
YES
NO
H
Alcohol and
Excessive use of alcohol and/or prescription drugs, or use of any illegal drugs; or treatment or
Drugs
recommendation for treatment of alcohol use or chemical dependency?
I
Vision
YES
NO
Do you wear glasses or contact lenses for driving?
YES
NO
Is your visual acuity worse than 20/40 in the better eye, even with corrective lenses?
YES
NO
Do you have degenerative or progressive eye condition?
YES
NO
Have you experienced a decrease in peripheral (side) vision?
YES
NO
J
Musculoskeletal
Loss or paralysis of all or part of an extremity; or onset of a general debilitating illness requiring
Chronic Debilities
treatment?
YES
NO
New or changed in the past 5 years?
YES
NO
Present longer than 5 years?
YES
NO
K
Alertness or
Do you have a condition that produces abnormal sleepiness (sleep apnea, narcolepsy, etc.?)
Sleep Disorders
YES
NO
L
Hearing
Only if you are a Commercial driver – no hearing requirements have been established for Regular
Impairment
Operator license.
YES
NO
Balance (ENT
Have you experienced any sudden vertigo or infection of the inner ear (vestibular neuronitis or
Problems)
labryinthitis?)
Other
YES
NO
Other health problems or use of medications which might interfere with driving ability or safety? Please
explain: _____________________________________________________________________
Answering yes to any of the above questions may result in a request for additional follow-up information.
Please print and take this completed form with you to the office.
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