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Assessment Checklist

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Temperature Testing (COVID 19)

Client Name *

First

Last

Accompanying Person

First

Last

Any other persons travelling with the client?

First

Last

Licence validated and recorded on report by

First

Last

Who was present?

First

Last

Who drove to the Mobility Centre?

First

Last

Emergency Contact Number

Tests and Leaflets Given to the Client

Completed Tests

Cognitive Tests
Eyesight Tests
Physical Test
DVLA Medical Questionnaire (if required)
D497

Leaflets Given to Client on Completion of Assessment

Disabled Driver Instructions Leaflet
Information Sheet Follow Up - Adaptations
Information Sheet Follow Up - Road Craft
DVLA Leaflet INF 231
DVLA Leaflet INF 231 A

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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