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Passenger Assessment Questionnaire

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Personal Details

All information provided is treated as confidential.

Full Name
For example, Miss, Mr, Mx, Dr.
Date of Birth

Height

Height - Choose to use either metric or imperial measurements

Weight

Weight - Choose to use either metric or imperial measurements

Other Information

Are you naturally right or left-handed?
Date and time of Assessment booking
Do you use any of the following? You can choose more than one.

Your Mobility

Can you walk unaided? (Without the aid of sticks, crutches or a care assistant).
For example '20 metres'.
For example '30 metres'.
Do you, or have you had any problems accessing and egressing (getting in and out of) a vehicle?

Your Car

Do you currently have a car?
Is your car an Estate, Hatchback, Saloon, or MPV (Multi Purpose Vehicle)?
For example, 'Volkswagon'.
For example, 'Polo'.
A Hatchback with two passenger doors is considered to be a 'three door'. Only include passenger doors here.
Whose idea was it to have a transfer / hoist assessment?

The Assessment

Have you had an assessment before?

Declaration

I hereby declare that all the above information is correct to the best of my knowledge.

Clear Signature

Herts Ability

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

Registered charity No. 1059015

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Contact

  • 01707 324581
  • 01707 371297

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