A: PERSONAL DETAILS
|
| Surname: | Date of Birth: |
| Forenames: | Tel No (inc code): |
| Address 1: | |
| Address 2: | |
| Address 3: | |
| Postcode: | |
| Position: | Dept: | |
B: YOUR HEALTH
|
| Have you suffered from any of the following during the last 12 months? Tick box |
| 1. Epilepsy | No | | Yes | |
| 2. Fit(s) or blackouts | No | | Yes | |
| 3. Severe and recurrent disabling giddiness | No | | Yes | |
| 4. Diabetes controlled by insulin | No | | Yes | |
| 5. Diabetes controlled by tablets | No | | Yes | |
| 6. An implanted pacemaker or defibrillator | No | | Yes | |
| 7. Angina (heart pain) which is easily provoked by driving |
No | | Yes | |
| 8. Persistent alcohol misuse or dependency | No | | Yes | |
| 9. Persistent drug misuse or dependency | No | | Yes | |
| 10. Parkinson’s disease | No | | Yes | |
| 11. Narcolepsy or sleep apnoea | No | | Yes | |
| 12. Stroke, with any symptoms lasting longer than one month, recurrent “mini strokes” or TIAs |
No | | Yes | |
| 13. Any type of brain surgery, severe head injury involving in-patient treatment, or brain tumour |
No | | Yes | |
| 14. Any other chronic neurological condition | No | | Yes | |
| 15. A serious problem with memory or episodes of confusion |
No | | Yes | |
| 16. Serious psychiatric illness or mental ill health for example diagnosis of anxiety/depression which required treatment from your GP/Specialist |
No | | Yes | |
| 17. Any visual condition affecting BOTH eyes or affecting your peripheral vision (visual field) (excluding short/long sight or colour blindness) |
No | | Yes | |
| 18. Any persisting limb problems which requires your driving to be restricted to certain types of vehicle or those with adapted controls |
No | | Yes | |
| 19. Sight in one eye only | No | | Yes | |
| 20. Visual problems affecting either eye | No | | Yes | |
| 21. Angina, other heart condition or heart operation |
No | | Yes | |
| 22. Any form of stroke, including minor or TIA | No | | Yes | |
C: DECLARATION AND AUTHORISATION
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| I confirm that the information given above is a true and accurate statement. I understand that if I have declared any of the conditions listed above, further medical investigations may take place. |
Signature:
| Date:
|
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