Name, address and telephone number of Doctor or Consultant
Does your Doctor believe you to be medically fit to drive? Please choose from the list Yes No
Please list the medication you take (if any)
Does your medication have any side effects that may affect your driving? Please choose from the list Yes No
Does your medication cause drowsiness? Please choose from the list Yes No
Do you suffer from blackouts or sudden attacks of dizziness? Please choose from the list Yes No
Do you have epileptic seizures? Please choose from the list Yes No
On what date did you have your last seizure?
Do you have any hearing problems? Please choose from the list Yes No
Do you use British Sign Language? Please choose from the list Yes No
Can you lip-read? Please choose from the list Yes No
What is your medical condition or disability and when was it diagnosed?
How does your condition/disability affect you?
Is the condition a progressive disorder (is it likely to worsen with time)? Please choose from the list Yes No
Is the condition likely to improve with time? Please choose from the list Yes No
Have you been diagnosed with dementia? Please choose from the list Yes No Other, please state
Please give details
If you have been diagnosed with dementia, which Memory Clinic have you attended and what is the name of the Doctor you were seen by?
Do you experience any pain? Please choose from the list Yes No
Please give details of the pain you experience
Do you have any special requirements, e.g. medication or continence issues that we should be aware of during your visit?
Do you have any problems with short-term memory? Please choose from the list Yes No
Do you have any spatial awareness difficulties (judgement of space)? Please choose from the list Yes No
Do you have any problems with dividing your attention on more than one task at the same time? Please choose from the list Yes No
Do you have any problems with concentration? Please choose from the list Yes No
Do you suffer from fatigue or tire very quickly? Please choose from the list Yes No
Do you have any learning difficulties? Please choose from the list Yes No
Do you have any problems with reading or writing? If so, please give details Please choose from the list Yes No
Are you dyslexic? Please choose the list Yes No
Do you have any problems with speech? Please choose from the list Yes No
Do you have any problems with understanding spoken words or following spoken instructions? Please choose from the list Yes No
Does anybody else who knows you have any concerns about your standard of driving? Please choose from the list Yes No
If so, who, and what are their concerns?
Are you experienced in driving manual transmission vehicles? Please choose from the list Yes No
Are you experienced in driving automatic transmission vehicles? Please choose from the list Yes No
Approximately when did you last drive?
Please state the problems you are experiencing whilst driving (if any)
Do you expect that you will require any vehicle adaptations in order to be able to physically control a motor vehicle? Please choose from the list Yes No
Have you had any collisions in the last five years (including minor incidents)? Please choose from the list Yes No
Please give as much detail as possible e.g. dates and what actually happened
Have you had any driving convictions in the past five years, (including minor convictions)? Please choose from the list Yes No
How many, and what were they for?
Do you currently have a car? Please choose Yes No
Is it a manual or automatic transmission? Please choose from the list Manual Automatic
Is you car an estate, hatchback, saloon or MPV (Multi Purpose Vehicle) Please choose from the list Estate Hatchback Saloon Multi Purpose Vehicle
What make and model is your car?
Does your car have any adaptations or modifications fitted to it? Please choose from the list Yes No
Please list the adaptations here
Does your car belong to you, or is it a Motability vehicle? Please choose from the list It belongs to me It is a motability vehicle
If you are a full licence holder, please state how many years you have been driving
Have you undertaken any driver training since gaining your full licence? Please choose from the list Yes No
Have you notified the DVLA of your medical condition or disability? Please choose from the list Yes No
Would you like your assessment to be conducted in: Please choose from the list A manual transmission car An automatic transmission car
How did you first hear about our assessment service?
Whose idea was it to have a driving assessment? DVLA Doctor Friend or relative Yours Other
If 'Other', whose idea was it?
Have you had a driving assessment before? Please choose from the list Yes No
Which assessment centre conducted the assessment last time?
What was the result of that assessment?
