Driver Licence Medical
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310,003 (04/2015)
Driver Licence Medical
Personal details
Other names
Surname
Given name
Business hours contact number
Date of birth
Licence number
Residential address
Medical pr actitioner details
Name of examini ng doctor (please print or stamp)
Signature
Date of examination
Address
Telephone
Medical examination - to be completed by medical practitioner
The examination must be conducted in accordance with the national medical standards described in ‘Assessing Fitness to Drive’.
This publication is available from the ACT Road Transport Authority or via the website at
How long have you treated the patient / how long has the patient attended this medical practice?
Do you know the medical history of the patient?
Yes
No
This application applies to:
A new licence application
An existing licence (include number)
The Licence Class for this application is:
Motorcycle
Car
Light rigid vehicle (vehicle up to 8 tonne GVM)
Visual Acuity - please specify
Was eye test conducted with corrective lenses?
Both
6/
Right
6/
Left
6/
Yes
No
Note: Eye test results and confirmation (yes or no) to corrective lenses must be recorded or the medical WILL NOT be accepted.
Does the patient have any of the following conditions?
Does this affect his
Is a driving assessment
or her ability
or review required by a
Please tick all boxes that apply.
to drive?
A tick indicates a positive response.
medical specialist?
Assessment:
Yes
No
Cardiovascular problems
Yes
No
Please specify
Review:
Yes
No
Diabetes
Insulin dependent
Assessment:
Yes
No
Yes
No
Tablets
Review:
Yes
No
Dietary
Epilepsy
Assessment:
Yes
No
Yes
No
/
/
Date of last attack
Review:
Yes
No
Mental / Psychiatric disorder
Assessment:
Yes
No
Yes
No
Please specify
Review:
Yes
No
Muscular / Skeletal disorders
Assessment:
Yes
No
Yes
No
Please specify
Review:
Yes
No
Neurological disorder
Assessment:
Yes
No
Yes
No
Please specify
Review:
Yes
No
Visual problems
Assessment:
Yes
No
Yes
No
Please specify
Review:
Yes
No
Road Transport Authority | PO Box 582 Dickson ACT 2602 | Phone: 13 22 81
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