(Fill in the form fields of all steps, check-mark YES or NO, and provide the relevant details)
We treat all the information you provide in this form as strictly confidential and it will be stored in accordance with the Data Protection Act 1998
1: Name & Address
2: Eyes & Neurology
3: Heart & Circulation
4: Diabetes
5: Respiratory & Psychiatric
6: General Health
7: Prescribed Drugs & Declaration
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Select the Medical Type: * Taxi MedicalHGV MedicalPSV Medical
Last Name * First Name * Date of Birth *
Address * Postal Code * Phone Number * Email Address *
Let's continue to the QUESTION SECTIONS.
EYES SECTION:
Q1: Do you suffer from any eye conditions that affect your vision e.g. double vision, glare loss of parts of your vision? * YesNo Provide Details to Q1
NEUROLOGY SECTION:
Q2: Have you ever had a TIA or stroke? * YesNo Provide Details to Q2
Q3: Have you ever had an unexplained episode of impaired consciousness/blackout/dizziness? * YesNo Provide Details to Q3
Q4: Have you ever had any serious brain injury, brain tumour, brain surgery, epileptic fit, narcolepsy or serious neurological disorder? * YesNo Provide Details to Q4
Let's continue to the next section: HEART AND CIRCULATION.
HEART & CIRCULATION SECTION:
Q5: History of heart attacks, angina or cardiac arrests? * YesNo Provide Details to Q5
Q6: Cardiac stents or bypass surgery? * YesNo Provide Details to Q6
Q7: Cardiac rhythm abnormality? * YesNo Provide Details to Q7
Q8: Any other serious heart condition? * YesNo Provide Details to Q8
Q9: A pacemaker or ICD implant? * YesNo Provide Details to Q9
Q10: High blood pressure? * YesNo Provide Details to Q10
Q11: Vascular disease of the legs? * YesNo Provide Details to Q11
Q12: Aortic aneurysm? * YesNo Provide Details to Q12
Q13: Any other serious heart condition? * YesNo Provide Details to Q13
Let's continue to the next section: DIABETES.
DIABETES SECTION:
Q14: Are you Diabetic? (If not, go to next section)* YesNo Provide Details to Q14
Q15: Are you treated with diet only? * YesNo Provide Details to Q15
Q16: Are you treated with tablets? (If so, please list them on section "Prescribed Drugs") * YesNo Provide Details to Q16
Q17: Are you treated with insulin or any other injectable treatment? * YesNo Provide Details to Q17
Q18: Do you check your blood sugars twice a day? * YesNo Provide Details to Q18
Q19: Do you check your sugars two hours before driving and every two hours whilst driving? * YesNo Provide Details to Q19
Q20: If on insulin, do you have a three month memory stick record of your blood sugars? * YesNo Provide Details to Q20
Q21: Have you ever have a "hypo" (low blood sugar/hypoglycaemic attack)? * YesNo Provide Details to Q21
Q22: If you have hypos, do you have full awareness of them? * YesNo Provide Details to Q22
Q23: Do you keep a fast acting carbohydrate within easy reach whilst driving? * YesNo Provide Details to Q23
Q24: Do you have a full understanding of diabetes and its complications? * YesNo Provide Details to Q24
Q25: Do you have any diabetic complications (eg eye, kidney or peripheral neuropathy? * YesNo Provide Details to Q25
Let's continue to the next section: RESPIRATORY & PSYCHIATRIC.
RESPIRATORY SECTION:
Q26: Do you have sleep apnoea syndrome? * YesNo Provide Details to Q26
Q27: If you do have sleep apnoea syndrome are you compliant with treatment, are your symptoms controlled and do you have an annual check? * YesNo Provide Details to Q27
Q28: Do you have any lung disorder that makes you very breathless? * YesNo Provide Details to Q28
PSYCHIATRIC SECTION:
Q29: Have you ever had any major psychiatric illness (severe depression, suicidal tendency, psychosis or bipolar disorder? * YesNo Provide Details to Q29
Q30: Do you have a history of significant alcohol or drug issues? * YesNo Provide Details to Q30
Q31: How many units of alcohol do you drink per week? * YesNo Provide Details to Q31
Let's continue to the next section: GENERAL HEALTH.
GENERAL HEALTH SECTION:
Q32: Do you have any physical disabilities (eg arm or leg deformity) that might affect your ability to drive? * YesNo Provide Details to Q32
Q33: Do you have severe deafness? * YesNo Provide Details to Q33
Q34: Do you take any medication that might cause drowsiness (eg strong pain killers or sedatives)? * YesNo Provide Details to Q34
Q35: Do you suffer from excessive daytime sleepness? * YesNo Provide Details to Q35
Q36: Do you have liver of kidney disease? * YesNo Provide Details to Q36
Q37: Have you had any cancer diagnosis in the past? * YesNo Provide Details to Q37
Let's continue to the next section: PRESCRIBED DRUGS & DECLARATION.
PRESCRIBED DRUGS:
Q38: Do you have any drugs that are regularly prescribed by your doctor. * YesNo Provide below the list of the drugs
DECLARATION:
I confirm this Declaration. I have provided answers for a vocational medical assessment to questions regarding my medical history, and, to the best of my knowledge and belief, they are correct. I give permission for a copy of these notes to be sent to my usual GP and for them to contact the examining doctor in the event of anything serious in the judgment of the attached medical should I have omitted any important details. I understand that I must inform the DVLA or other Licencing Authority of any significant change in my health
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