Nsw Medical Assessment Form Page 2
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7Medical Assessment Form Public Passenger Vehicle Driver continued
13.
Do you use any drugs or medications not prescribed for you
j. Seizures, Fits, Convulsions, Epilepsy
by a doctor which may affect your ability to drive a motor
Yes
vehicle?
No
Yes
if yes give details
No
k. Blackouts, Fainting
Yes
Details
No
l.
Stroke
14.
Do you have diabetes?
Yes
how is this being treated?
Yes
Diet
No
No
Tablets
m.
Dizziness, Vertigo (balance problems)
Insulin
Yes
15.
In the past year, have you ever had to pull off the road
No
because you have become sleepy or drowsy?
n.
Double Vision, Difficulty seeing (other than needing glasses)
Yes
if yes give details
Yes
No
No
Details (If so, how often?)
o.
Kidney disease
Yes
No
16.
Have you ever had, or been told by a doctor that you had
any of the following?
p.
Sleep Disorder, Sleep Apnoea or Narcolepsy
a.
High Blood Pressure
Yes
Yes
No
No
q.
Cancer (affecting brain or nervous system)
Heart Disease
b.
Yes
Yes
No
No
Note: If you have answered yes to any questions in section 16,
c.
Chest pain, Angina
please have your Medical Practitioner (doctor) provide details
in 'Doctor's comments' on page 7'.
Yes
No
17.
Alcohol Use Questionnaire
a.
How often do you have a drink containing alcohol?
d.
Any Heart operation or procedure
Yes
Never
go to question 18
No
Monthly or less
2 to 4 times a month
e.
Palpitations/Irregular heart beat
2 to 3 times a week
4 or more times a week
Yes
b.
How many drinks containing alcohol do you have on a
No
typical day when you are drinking?
f.
Abnormal shortness of breath
1 or 2
3 or 4
Yes
5 or 6
7, 8 or 9
No
10 or more
g.
Head injury, spinal injury
c.
How often do you have six or more drinks on one occasion?
Yes
Never
Less than monthly
No
Monthly
Weekly
h.
Psychiatric, Psychological, Nervous Disorder or Depression
Daily or almost daily
Yes
No
d. How often during the last year have you found that you were
not able to stop drinking once you had started?
i. Hearing Loss
Never
Less than monthly
Yes
Monthly
Weekly
No
Daily or almost daily
continued page 3
Catalogue No. 45071751 Form No. 1689 (03/2016) ABN 76 236 371 088
Page 2 of 7
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