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Driving

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Personal Details Part 1

Title *

For example, Miss, Mr, Mx, Dr.

1. Name *

First

Last

2. Date of Birth

Contact Details

3. Email *

Email

Confirm Email

Do you give consent for your assessment report to be sent to you electronically on the email address above?

Yes
No

Please note, if you have been referred to Herts Ability via the DVLA the report will be sent directly to them. You can request a copy by contacting the DVLA.

4. Landline Phone Number

5. Mobile Phone Number *

What is the best number to contact you on? *

Please list your postcode in the box below as shown on your driving licence

Personal Details Part 2

Height

Height - Choose to use either metric or imperial measurements

Metric (centimetres)
Imperial (feet and inches)

6. What is your height in centimetres?

Centimetres ( cm )

6. What is your height in feet and inches?

Feet ( " )

Inches ( ' )

Weight

Weight - Choose to use either metric or imperial measurements

Metric (kilograms)
Imperial (stones and pounds)

7. What is your weight in kilograms?

Kilograms

7. What is your weight in stones and pounds?

Stones

Pounds

8. Did you complete this form yourself?

Yes
No

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

9. What would you like to achieve during your assessment?

Medical and Health Information

10. What is your medical condition or disability and when was it diagnosed?

11. Has your medical condition/disability changed how you complete your daily activities?

Yes
No
Not sure

If your medical condition has changed, please provide details.

12. Name, address and telephone number of GP or Specialist consultant

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

Yes
No

If no, please provide details in the comments box below.

Medication and Other Requirements

14. Please list the medication you take (if any)

15. Does your medication have any side effects that may affect your driving? For example, Drowsiness or Dizziness.

Yes
No

15.1 If you said yes, please state what side effects you experience.

16. Do you suffer from blackouts or sudden attacks of dizziness?

Yes
No

17. Do you have epileptic seizures? If yes, please answer Question 18.

Yes
No

18. When was the last date of your seizure?

19. Do you suffer from fatigue or tire very quickly?

Yes
No

20. Do you have any problems with cognition e.g short term memory, dividing your attention on more than one task at the same time, or concentration?

Yes
No

21. Do you have any learning difficulties or special educational needs?

Yes
No

22. Do you have any problems with reading, writing or speech?

Yes
No

23. Do you have any hearing problems?

Yes
No

24. Do you have any special requirements, e.g. medication or continence issues that we should be aware of during your visit?

25. Have you attended a Memory Clinic? If yes, what was the name of the Clinic and Doctor you were seen by?

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

Yes
No

Eyesight

27. When did you last have your eyesight tested?

28. Did the optician state your vision as being legal for driving at that time?

Yes
No
Not stated
Unsure

29. Do you wear glasses or contact lenses for driving?

Yes
No

30. Do you have any eyesight related conditions?

Yes
No

If yes, please provide details

31. Have you been diagnosed with a visual field deficit? If yes, please provide details in the comments box below

Yes
No

If yes, please provide details

Mobility and Physical Ability

32. Do you experience any pain? If yes, please move on to question 34. If no, move to question 35

Yes
No

33. Please give details of the pain you experience and where in your body

34. Do you experience any mobility difficulties? If yes, move to Question 36. If no move to question Question 41

Yes
No

35. Can you walk with or without a walking aid for approximately 100 metres/yards?

Yes
No

36. Do you use a wheelchair?

Yes
No

37. Can you transfer into a car without help from others?

Yes
No

38. If you use any equipment to assist you with transfers to and from a car, please give details below.

39. Do you have any other physical difficulties we should be aware of?

Driving History

40. Approximately when did you last drive?

41. What type of vehicle are you used to driving?

Manual
Automatic
Both
None

42. Please state the problems you are experiencing whilst driving (if any)

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

Yes
No

If yes, please provide details of that person.

44. Do you expect that you will require any vehicle adaptations in order to be able to physically control a motor vehicle?

Yes
No
Not sure

45. Do you have a car? If yes, please move to question 47, if no, move to question 50

Yes
No

46. Is your car manual or automatic?

Manual
Automatic

47. What make and model is your car?

For example, 'Volkswagon, Polo'

48. If your car has any adaptations or modifications, please list them below.

49. If you have had any road accidents and/or collisions in the last five years (including minor incidents), please give a brief description below.

50. If you are a full licence holder, please state how many years you have been driving

Driving History (continued)

51. What type of vehicle would you like your assessment to be conducted in?

Manual
Automatic
Both
Adaptations
Unsure

52. Who suggested you come for a driving assessment, e.g. DVLA, GP, memory clinic, healthcare professional?

53. If you have had a driving assessment before, please provide details below?

54. Typically where do you drive to on your average week?

55. If you don't currently drive, which methods of transport do you use?

NOTE: ONLY PROVISIONAL LICENCE HOLDERS NEED TO ANSWER THE FOLLOWING FOUR QUESTIONS

If you are a Full Licence holder, move to the Ethnic Origin section.

Provisional Licence holders move to Question 57.

56. How many hours driving tuition have you taken?

57. Have you passed your theory test yet?

Yes
No

59. Have you previously participated in any practical driving tests?

Yes
No

59. How many practical tests have you taken?

Ethnic Origin

If you choose not to complete this section, please check the box.

Does not wish to respond

If you have chosen not to respond, please press 'Next' below to proceed.

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

Consent

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

I authorise
I do not authorise

I give Herts Ability consent to send a copy of my driving assessment report to the DVLA on my behalf. *

I authorise
I do not authorise

I agree that the outcome of my assessment (including my report) can be sent to a healthcare professional (where specified) so they can support me further when discussing my fitness to drive. *

I authorise
I do not authorise

Your Licence Status

In order for us to conduct your assessment, we need to check your licence status in advance.

Please insert your full Driving Licence number and National Insurance (NI) number below.

This information is essential for us to check your driving licence before arrival. Once a licence check is complete, your National Insurance Number will be permanently removed from our systems.

Example National Insurance card:

Example of a UK National Insurance card.

National Insurance (NI) Number *

It’s on your National Insurance card, benefit letter, payslip or P60. For example, ‘AB 12 34 56 C’.

Example driving licence number highlighted in blue:

Example Driving Licence showing the Driver Number

Driving Licence Number

Please provide your full Driving Licence number. These details will be destroyed once your assessment has been completed.

Your postcode as it appears on your driving licence

If you have not provided a Driving Licence number, please tick the box below and provide the reason why.

I have not provided a Driving Licence number

Reason why you have not provided your Driving Licence number.

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

Name

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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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