Driver Licence Medical Page 2
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1
2
3Medical examination continued
Does the patient have any of the following conditions?
Does this affect his
Is a driving assessment
or her ability
Please tick all boxes that apply.
or review required by a
A tick indicates a positive response.
to drive?
medical specialist?
The applicant is on medication which would
Assessment:
Yes
No
adversely affect his / her ability to drive (please list)
Yes
No
Review:
Yes
No
Other
E.g. Excessive use of alcohol and drugs, blackouts,
Assessment:
Yes
No
dizziness or metabolic / endocrine, hearing, liver, renal,
Yes
No
respiratory, sleep, syncope and / or vestibular disorders.
Review:
Yes
No
Please specify
Medical opinion - medical practitioner to complete
I certify that I have examined the afore mentioned patient in accordance with the National Medical Standards (Private) as set out
in ‘Assessing Fitness to Drive’. In my opinion the person subject of this report:
Medical Opinion
Action Required
Meets the relevant medical criteria for an unconditional licence.
If no further medicals are required, indicate reasons
in the box provided.
Does not meet the medical criteria for an unconditional or a
conditional licence.
Examining doctor to clearly note in the box provided:
1) Criteria not met and other relevant medical details
Does not meet the medical criteria for an unconditional licence but
may be suitable for a conditional licence based on opinion below and
Examining doctor to clearly note in the box provided:
additional details attached as required.
1) Criteria not met and other relevant medical details.
2) Proposed restrictions to licence (if appropriate).
3) Suggestions for management and periodic
review interval (conditional licence).
Specialist report was obtained and is attached / summarised below.
Examining doctor to obtain required information from
specialist and attach report or summarise findings.
Requires practical driving test and is medically and psychologically fit
to undertake a test.
Examining doctor to clearly note in the box provided,
details regarding the medical condition as relevant to
the driving task.
Requires occupational therapist assessment and is medically and
psychologically fit to undertake an occupational therapist assessment.
Examining doctor to clearly note in the box provided,
details regarding the medical condition as relevant to
the driving task.
Requires an assessment by the Fitness to Drive Medical Clinic.
Examining doctor to clearly note in the box provided,
details regarding the medical condition as relevant to
the driving task.
Privacy statement: The information sought on this form is to assess your compliance with the required medical standards. The lawful authority
for collecting this information is the Road Transport (Driver Licensing) Regulation 2000. The information may be disclosed to Commonwealth,
Territory or State law enforcement agencies; transport authorities in those jurisdictions; and government agencies authorised by law. The
information may also be disclosed to medical professionals and driving assessors only as is needed to assess your ability to drive safely.
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