Health Assessment For Fitness To Drive Page 2
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3IN-CONFIDENCE WHEN COMPLETED
THIS FORM SHOULD BE RETAINED BY THE EXAMINING DOCTOR
6.
Psychological health (Refer AFTD p 100-104)
3.
Cardiovascular system (refer AFTD p 37-55)
Relevant findings from questionnaire:
Relevant findings from questionnaire:
Mental state examination:
Appearance …………….
Blood pressure
Repeated (if necessary)
Normal
Abnormal
Attitude…………………..
Normal
Abnormal
Systolic
Systolic
Behaviour………………..
Normal
Abnormal
Diastolic
Diastolic
Mood and affect…………
Normal
Abnormal
Thought form stream and
Normal
Abnormal
Pulse rate
content……………...
beats/min
Normal
Abnormal
Perception……………….
Normal
Abnormal
Heart sounds
Normal
Abnormal
Cognition…………………
Normal
Abnormal
Peripheral pulses
Normal
Abnormal
Insight…………………….
Normal
Abnormal
Judgement……………….
Normal
Abnormal
Comments (including comments regarding overall cardiac
risk and risk factors e.g obesity, smoking, exercise, stress):
Comments:
7.
Sleep disorders (Refer AFTD p 105-109)
4.
Diabetes (Refer AFTD p 56-62)
Existing sleep disorder?
No
Yes
Existing diabetes?
No
Yes
ESS Score (Screen):
(Q 5 of Driver Health Questionnaire)
Comments:
(Score > 16 is consistent with moderate to severe excessive
daytime sleepiness)
Clinical signs of sleep
Absent
Present
disorder
Comments:
5.
Musculoskeletal / neurological system
(Refer AFTD p 66-69)
Relevant findings from questionnaire:
8.
Substance misuse (Refer AFTD p 110-115)
Note: Drug screening not routinely required.
Existing substance use
No
Yes
disorder?
Cervical spine rotation
Normal
Abnormal
Audit Score (Screen):
Back movement
Normal
Abnormal
(Q6 of Driver Health Questionnaire)
Upper
(a) Appearance
Normal
Abnormal
limbs:
(Score > 8 indicates strong likelihood of hazardous or
(b) Joint movements
Normal
Abnormal
harmful alcohol consumption)
Lower
(a) Appearance
Normal
Abnormal
Clinical signs of
limbs:
Absent
Present
(b) Joint movements
Normal
Abnormal
substance misuse
Reflexes
Normal
Abnormal
Comments:
Romberg’s sign*
Normal
Abnormal
(* 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)
9.
Medication
Comments:
Specify:
Clinical Assessment Record – Page 2 of 3
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