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Vital Health Checks > Clinical Assessment Record

Assessing Fitness to Drive 2016

Health Assessment for Commercial Vehicle Driver

CLINICAL ASSESSMENT RECORD

    • 1

      General Information

    • 2

      Clinical Assessment

    • 3

      Summary

    1/3

    General Information

    Driver information:

    Employer information:

    Nature of driving duties:

    Clinical Assessment:

    1. Vision

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

    Are glasses or contact lenses worn?

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

    Meets criteria

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

    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?

    If yes, are hearing aids worn ?

    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

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

    Blood pressure Repeated (if necessary)
    Systolic Systolic
    Diastolic Diastolic

    Pulse rate beats/min

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

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

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

    (* 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?

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

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

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

    Existing sleep disorder?

    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

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

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

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

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

    Clinical signs of substance misuse

    9. Medication

    Summary:

    Are any further investigations or referrals required?

    What is the recommendation for this driver in terms of fitness to drive?


    Contact(s) with other treating health professional(s)
    Note: Contact is to be made with patient’s consent as per questionnaire

    Contact with requesting organisation (if relevant and clinically warranted)

    Details of contact made

    Signature of doctor: