Health Assessment For Fitness To Drive (Page 3 of 3) in pdf

Health Assessment For Fitness To Drive Page 3

IN-CONFIDENCE WHEN COMPLETED

THIS FORM SHOULD BE RETAINED BY THE EXAMINING DOCTOR

SUMMARY

Summarise significant findings

Are any further investigations or referrals required?

Yes (describe)

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

Unconditionally meets the medical criteria – meets all relevant medical criteria (no restrictions)

Conditionally meets the medical criteria for fitness to drive – has a medical condition that may impact on

fitness to drive but it is well controlled and meets the conditional criteria in Assessing Fitness to Drive 2012.

Indicate also if:

Driver requires aids to drive:

Vision aids

Hearing aids

Other devices or vehicle modifications (specify)

Driver r

equires

more frequent review than prescribed under normal periodic review:

Specify recommended review:

Temporarily does not meet the medical criteria (unconditional or conditional) – pending further investigation

and treatment (record details).

Permanently does not meet the medical criteria (record details)

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)

If the driver is classified Temporarily or

Details of contact made

Permanently does not meet the medical criteria,

send Fitness to Drive Report immediately to

requesting organisation, if relevant.

Name of doctor

Signature of doctor

Date

Clinical Assessment Record – Page 3 of 3

Health Assessment For Fitness To Drive Page 3