Clinical Assessment Record

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General Information

Driver information:

Surname:

Given name(s):

Date of birth:

Phone:

Driver licence number:

State of issue:

Address:

Employer information:

Employer name:

Phone:

Address:

Nature of driving duties:

Clinical Assessment:

1. Vision

1.1 Visual acuity (refer AFTD, page 124, 129)

Are glasses or contact lenses worn? YesNo

	R	L	Both
Without Correction	6/	6/	6/
With Correction	6/	6/	6/

Meets criteria Without correctionWith correctionDoes not meet criteria

1.2 Visual Fields (refer AFTD, page 125-26, 128)

NormalAbnormal

Comments::

2. Hearing (refer AFTD, page 67-69 including flowchart)

Assess clinically in the first instance. Audiometry is only required if clinical assessment indicates possible hearing loss. (Clinical tests used to screen for hearing impairment include testing whether a person can hear a whispered voice, a finger rub, or a watch tick at a specific distance. Perceived hearing loss can be assessed by asking a single question (for example, “Do you have difficulty with your hearing?” as per the Driver Health Questionnaire)

Possible hearing loss?
YesNo

If yes, are hearing aids worn ?
YesNo

Refer for audiometry if indicated: Hearing level at frequencies (db)
	0.5kHz	1.0kHz	1.5kHz	2.0kHz	3.0kHz	4.0kHz	6.0kHz	8.0kHz	Average of 0.5,1,2,3 kHz
Right ear
Left ear

Meets criteria Without hearing aidWith hearing aidDoes not meet criteria

Comments:

3. Cardiovascular system (refer AFTD page 39-58)

Relevant findings from questionnaire:

Blood pressure		Repeated (if necessary)
Systolic		Systolic
Diastolic		Diastolic

Pulse rate beats/min

Comments (including comments regarding overall cardiac risk and risk factors e.g. obesity, smoking, exercise, stress):

4. Diabetes (Refer AFTD page 59-66)
Existing diabetes? YesNo

Comments:

5. Musculoskeletal / neurological system (Refer AFTD page 71-75, 76-105)

Comments include relevant findings from questionnaire including existing neurological and musculoskeletal conditions:

Cervical spine rotation	NormalAbnormal
Back movement	NormalAbnormal
Cervical spine rotation	(a) Appearance	NormalAbnormal
	(b) Joint movements	NormalAbnormal
Reflexes	NormalAbnormal
Romberg’s sign*	NormalAbnormal

(* A pass requires the ability to maintain balance while standing with shoes off, feet together side by side, eyes closed and arms by sides, for thirty seconds)

Functional/ practical assessment required?
NoYes

Comments:

6. Psychological health (Refer AFTD page 107-110)

Relevant findings from questionnaire:

Mental state examination:
Appearance	NormalAbnormal
Attitude	NormalAbnormal
Behaviour	NormalAbnormal
Mood and affect	NormalAbnormal
Thought form stream and content	NormalAbnormal
Perception	NormalAbnormal
Insight	NormalAbnormal
Cognition	NormalAbnormal
Judgement	NormalAbnormal

Comments:

7. Sleep disorders (Refer AFTD page 112-115)

Existing sleep disorder? YesNo

ESS Score (Screen):
(Q 5 of Driver Health Questionnaire)

(Score > 16 is consistent with moderate to severe excessive daytime sleepiness. Do not rely solely on the ESS to rule out sleep apnoea)

Clinical signs of sleep disorder AbsentPresent

Comments:

8. Substance misuse (Refer AFTD page 117 -121)

Note: Drug screening not routinely required. Existing substance use disorder?

NoYes

Audit Score (Screen):
(Q6 of Driver Health Questionnaire)

(Score > 8 indicates strong likelihood of hazardous or harmful alcohol consumption)

Clinical signs of substance misuse AbsentPresent

Comments:

9. Medication

Specify:

Health Assessment for Commercial Vehicle Driver

Driver information:

Employer information:

Nature of driving duties:

Clinical Assessment:

1. Vision

1.1 Visual acuity (refer AFTD, page 124, 129)

1.2 Visual Fields (refer AFTD, page 125-26, 128)

2. Hearing (refer AFTD, page 67-69 including flowchart)

3. Cardiovascular system (refer AFTD page 39-58)

5. Musculoskeletal / neurological system (Refer AFTD page 71-75, 76-105)

6. Psychological health (Refer AFTD page 107-110)

7. Sleep disorders (Refer AFTD page 112-115)

8. Substance misuse (Refer AFTD page 117 -121)

9. Medication

Summary: