Main Site

Pre-Assessment Form

Complete this form before booking an assessment

On completion of this form, a member of the Herts Ability team will be in touch to arrange a suitable date for your assessment.

Please enable JavaScript in your browser to complete this form.

What are you booking?

Details of the Person Being Assessed

First Name

Last Name

Address

Address

Type a POSTCODE and select the correct address from the options. Add a HOUSE number in the next box.

House number or name

Enter the HOUSE number or name here.

Other Details

Landline Phone Number *

Mobile Phone Number *

Email Address *

Date of Birth

How did you hear about us?

Preparing for the Assessment

What type of licence do you currently have?

Full
Provisional
PDAL Licence
No licence

Has anyone referred you for an assessment?

Yes
No
Not sure

Have you informed DVLA of your medical condition?

Yes
No

What is your disability or medical condition?

Do you use a wheelchair?

Yes
No

Can you transfer into a vehicle independently?

Yes
No

Please provide any additional information about your mobility.

Driving Experience

When did you last drive?

Month

Year

No previous driving experience

Select this option if you have never driven

Eyesight and Vision

Have you had a visual field test?

Yes
No

Have you ever had problems with visual awareness on one side (e.g. inattention or neglect)?

Yes
No

When did you last have your vision checked?

Month

Year

No previous vision check

Select this option if you have never had your vision checked.

Your Height

Height - Choose to use either metric or imperial measurements

Metric (centimetres)
Imperial (feet and inches)

What is your height in centimetres?

Centimetres

What is your height in feet and inches?

Feet

Inches

Your Weight

Weight - Choose to use either metric or imperial measurements

Metric (kilograms)
Imperial (stones and pounds)

What is your weight in kilograms?

Kilograms

What is your weight in stones and pounds?

Stones

Pounds

Driving Requirements

What type of vehicle do you currently drive?

Do you wear glasses or contact lenses for driving?

Yes
No

Would you like to drive a manual or automatic transmission vehicle?

Manual
Automatic

Do you believe that you will require adaptations in order to drive?

Yes
No

If you currently use adaptations to drive please list them below.

Is there anything else you'd like to tell us before your assessment?

Your Assessment

Would you be interested in a cancellation if we get one?

Yes
No

Which assessment centre would you prefer your assessment take place?

Welwyn Garden City
East London
Harlow
Leatherhead
Luton
Stotfold
Watford

Booking Date and Time

Date

Time

How was payment made?

Consent to use your Personal Data

Please tick the box provide consent for us to use your personal data. We don't pass your data on to anyone.

Your personal data is kept confidential and only used for the purposes relating to this form and in accordance with our Privacy Policy.

Website

Save and Resume Later

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.

Copy Link

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

Social Media

Facebook
Instagram
X (Twitter)
LinkedIn

© 2025 Herts Ability. All right reserved.