IN-CONFIDENCE WHEN COMPLETED
THIS FORM SHOULD BE RETAINED BY THE EXAMINING HEALTH PROFESSIONAL
Assessing Fitness to Drive 2016
(to be completed by driver)
General Information
Instructions for completion:
Questions:
Declaration
1/4
Surname:
Given name(s):
Date of birth:
Phone:
Driver licence number:
State of issue:
Address:
Employer name:
Please answer the questions by ticking the appropriate box. If you are not sure what a question means, leave the answer blank and the health professional will help you. The health professional will ask you additional questions during the assessment. On completion of the questionnaire you will be asked to sign a declaration to confirm the accuracy of your responses. Please bring with you to the assessment:
A list of current prescription, non-prescription and complementary medicines
Glasses/contact lenses and hearing aids if you use them
Disease management plans (e.g. sleep disorder management plan, diabetes management plan)
Please read carefully and sign to indicate you understand how health information is reported, stored and accessed. The details of your health assessment will remain confidential and will only be reported to the requesting organization in terms of whether you meet the medical criteria for driving a commercial vehicle. The examining health professional retains all detailed health documentation including your questionnaire responses and the completed record of clinical findings. The examining health professional will provide you with the report form to return to the requesting organization indicating your fitness for duty classification. Other than the above, your personal information will not be disclosed to any other person or organization without your written permission, except when required by law. You have the right to access your health records including those held by the examining health professional and the reports held by the requesting organization.
Driver’s declaration I have read and understood the above statement concerning the health information provided in this document.
Signature of driver
Date
I consent to the examining doctor contacting my treating health professionals to clarify aspects of my medical management.
1. Are you currently attending a health professional for any illness, injury or disability?
NoYes
2. Are you taking any prescription, non-prescription or complementary medicines?
If YES to Question 1 or 2 please provide brief details:
Health professional’s comments:
3.1 High blood pressure
3.11 Stroke
3.2 Heart disease
3.12 Dizziness, vertigo, problems with balance
3.3 Chest pain, angina
3.13 Memory loss or difficulty with attention or concentration
3.4 Any condition requiring heart surgery
3.14 Other neurological disorder
3.5 Palpitations / irregular heartbeat
3.15 Neck, back or limb disorders
3.6 Abnormal shortness of breath
3.16 Double vision, difficulty seeing
3.7 Diabetes
3.17 Colour blindness
3.8 Head injury, spinal injury
3.18 Hearing loss or deafness or had an ear operation or use a hearing aid
3.9 Seizures, fits, convulsions, epilepsy
3.19 A psychiatric illness or nervous disorder
3.10 Blackouts or fainting
4. Have you ever had any other serious injury, illness, disability, operation or accident or been in hospital for any reason? (please describe).
5. Sleep
5.1 Have you ever been tested for a sleep disorder or been told by a doctor that you have a sleep disorder, sleep apnoea or narcolepsy?
5.2 Has anyone told you that your breathing stops or is disrupted by episodes of choking during your sleep?
5.3 How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. If you haven’t done some of these things recently try to work out how they would have affected you.
would never doze off (0)
slight chance of dozing (1)
moderate chance of dozing (2)
high chance of dozing (3)
a. Sitting and reading
0
1
2
3
b. Watching TV
c Sitting inactive in a public place (e.g. a theatre or a meeting)
d. As a passenger in a car for an hour without a break
e. Lying down to rest in the afternoon when circumstances permit
f. Sitting and talking to someone
g. Sitting quietly after a lunch without alcohol
h. In a car, while stopped for a few minutes in the traffic
6. Alcohol
6.1 Have you ever sought assistance for alcohol or substance use issues?
6.2 Please select the answer that best describes your situation.
(0)
(1)
(2)
(3)
(4)
a. How often do you have a drink containing alcohol?
Never
Monthly or less
2 to 4 times per month
2 to 3 times per week
4 or more times per week
b. How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2
3 to 5
5 to 6
7 to 9
10 or more
c. How often do you have six or more drinks on one occasion?
d. How often during the last year have you found that you were not able to stop drinking once you had started?
e. How often during the last year have you failed to do what was normally expected from you because of drinking?
f. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?
g. How often during the last year have you had a feeling of guilt or remorse after drinking?
h. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
i. Have you or someone else been injured as a result of your drinking?
No
Yes, but not in the last year
Yes, during the last year
j. Has a relative or friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down?
Other 7. Do you currently use illicit drugs? NoYes
8. Do you use any drugs or medications not prescribed for you by your doctor? NoYes
9. Have you been in a vehicle crash since your last fitness to drive examination? NoYes
Signature of examining medical practitioner
Submit
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