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Driving Assessment Questionnaire

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Personal Details

Name *

First

Last

Email *

Confirm Email

Landline Phone Number

Mobile Phone Number

Date of Birth

What is your height?

Use Feet and Inches
Use Centimetres

Feet ( " )

Inches ( ' )

Centimetres (cm)

What is your weight?

Use Stones and Pounds
Use Kilograms

Stone (st)

Pounds (lb)

Kilograms

Did you complete this form yourself?

Please give the name and relationship of the person that completed this form on your behalf

Are you naturally left or right handed?

Left Handed
Right Handed

Are you employed, unemployed or retired?

Occupation or Educational Status

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Medical and Health Information

Name, address and telephone number of Doctor or Consultant

Please answer the following questions including any information that you feel may be relevant to driving

Does your Doctor believe you to be medically fit to drive?

Please list the medication you take (if any)

Does your medication have any side effects that may affect your driving?

Does your medication cause drowsiness?

Do you suffer from blackouts or sudden attacks of dizziness?

Have you experienced a seizure?

On what date did you have your last seizure?

Do you have any hearing problems?

Do you use British Sign Language?

Can you lip-read?

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)?

Is the condition likely to improve with time?

Have you been diagnosed with dementia?

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 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?

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Memory, Attention and Understanding

Please answer YES or NO to the following questions and give details where appropriate

Do you have any problems with short-term memory?

Do you have any spatial awareness difficulties (judgement of space)?

Do you have any problems with dividing your attention on more than one task at the same time?

Do you have any problems with concentration?

Do you suffer from fatigue or tire very quickly?

Do you have any learning difficulties?

Do you have any problems with reading or writing?

Are you dyslexic?

Do you have any problems with speech?

Do you have any problems with understanding spoken words or following spoken instructions?

Does anybody else who knows you have any concerns about your standard of driving?

If you have answered 'Yes' to any of the questions above, please provide relevant details here.

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Eyesight

What date did you last have your eyesight tested?

Who carried out this assessment?

What was the outcome of this check?

Was your vision stated by the optician as being legal for driving at that time?

Do you wear glasses?

Do you wear contact lenses?

Please state when you wear your glasses or contact lenses (reading, TV, driving, full-time etc.)

Do you suffer from diplopia (double vision)?

Do you currently have, or have you ever had, any problems with visual awareness on one side – such as visual inattention or neglect?

Do you have any other eyesight related conditions?

Please give details

Have you had your visual fields checked by a professional?

What date did you have them checked?

What was the outcome of this check?

Have you had any other eyesight related conditions that you no longer suffer from?

Please give details

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Mobility

Can you walk unaided (without the aid of sticks, crutches or a care assistant)?

How far can you walk unaided?

Can you walk with the aid of sticks or crutches? If so, how far can you walk?

If you use a wheelchair, can you transfer into a vehicle without help from others?

Do you use any equipment to assist you with transfers in/out of a car?

Please give details of transfer equipment

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Driving Information

Are you experienced in driving manual transmission vehicles?

Are you experienced in driving automatic transmission vehicles?

Approximately when did you last drive?

Month

Year

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?

Have you had any collisions in the last five years (including minor incidents)?

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)?

How many, and what were they for?

About Your Car

Do you currently have a car?

Is it a manual or automatic transmission?

Manual
Automatic

Is you car an estate, hatchback, saloon or MPV (Multi Purpose Vehicle)

What make and model is your car?

Model of car

Does your car have any adaptations or modifications fitted to it?

Please list the adaptations here

Does your car belong to you, or is it a Motability vehicle?

Licence and Training

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 provide details of your driver training

Have you notified the DVLA of your medical condition or disability?

The Assessment

Would you like your assessment to be conducted in:

How did you first hear about our assessment service?

Whose idea was it to have a driving assessment?

If 'Other', whose idea was it?

Have you had a driving assessment before?

Which assessment centre conducted the assessment last time?

What was the result of that assessment?

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NOTE: Only Provisional licence holders need to answer the following three questions.

How many hours driving tuition have you taken?

Have you passed your theory test yet?

Have you previously participated in any practical driving tests?

How many practical tests have you taken?

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Ethnic Origin

White

British
Irish
Any other white background

Mixed

White & Black Caribbean
White & Black African
White & Asian
Any other Mixed background

Please state other White background

Please state other Mixed background

Asian or Asian British

Indian
Pakistani
Bangladeshi
Any other Asian background

Black or Black British

Carribean
African
Any other Black background

Please state other Asian background

Please state other Black background

Chinese or other ethnic group

Chinese
Any other ethnic group

Other ethnic group

Response declined

Do not wish to respond

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Consent

Do you grant consent for details of your assessment to be discussed with a third party such as a family member, case worker etc? *

Do you grant consent for your assessment report to be sent to you electronically? (Note, that if you have been referred by the DVLA, our report is sent to them rather than yourself) *

Your Email *

I authorise my Doctor(s) and/or Specialist(s) to release reports to the Mobility Centre about my medical condition *

I AUTHORISE
I DO NOT AUTHORISE

I authorise the Mobility Centre to release information to my Doctors and/or Specialists about the outcome of my case (this is to enable your Doctor to advise you about your fitness to drive) *

I AUTHORISE
I DO NOT AUTHORISE

The GDPR Act 2018 requires us to seek your written consent to our processing the information provided by you on this form. Some of this information may be given to a third party, such as Approved Driving Instructors or adaptation companies who may be assisting you following your assessment. Only occasionally do we need to do this and it may well not apply in your case.

We never, under any circumstances release information which is not relevant to your fitness to drive, or discuss your personal details. Your signature will be taken to mean that you have given this consent. Under exceptional circumstances, it may also be necessary for us to notify the DVLA or our findings. We will keep your data for a period of two years and then it will be destroyed.

Under the Data Protection Act, you have the right to enquire in writing, what personal information the Mobility Centre is holding about you and, subject to a few limited exceptions, to be supplied with a copy of this information.

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Declaration

Signature. This is a required field. *

Clear Signature

Use your mouse pointer or finger to draw your usual signature. You can try as many times as you need by clicking or tapping the cross icon on the right to clear the box.

Date / Time *

Date

Time

Your National Insurance Number and your Driving Licence Number will be used solely to ensure you are licenced to drive for the duration of your assessment. These details will be destroyed once your assessment has been completed

Please provide your National Insurance number

Please also provide your Driving Licence number below

Message

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Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternately, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *

Herts Ability

Suite 4, Wentworth Lodge
Great North Road
Welwyn Garden City
Hertfordshire
AL8 7SR

Registered charity No. 1059015

Contact

01707 324581
01707 371297

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