Occupational Health Service

MEDICAL ASSESSMENT FOR DRIVING

PERSONAL DETAILS

Name .………………………………………………………………. Date of Birth ……………………………………………

Location .……………………………………………………………. Job Title .……………………………………………….

To be completed by employee

Type of vehicle driven at work ………………………… Type of licence held (eg ordinary, HGV, PCV) ………………..

Type of driving duties ……………………………………………………………………………………………………………

Have you ever had … / Yes / No
1. A condition affecting your heart or circulation, including any of the following: heart attack, angina, valve disease, heart surgery, high blood pressure, pacemaker, other?
2. Diabetes?
3. A condition affecting your nervous system including any of the following: epilepsy, fit, brain surgery, stroke, head injury requiring hospital admission, blackouts, dizzy spells, hearing problems, brain tumour/haemorrhage, other?
4. A mental illness, including any of the following: depression, panic attacks, schizophrenia, mania, admission to a psychiatric hospital, other?
5. A condition affecting your eyesight including any of the following: cataract, glaucoma, eye injury, double vision, other?
6. Have you had your eyes tested in the past 2 years?
7. A condition affecting your joints or mobility?
8. Do you have difficulties with Neck movements
Upper limb movements Lower limb movements
9. Any other condition that might affect your driving?
10. Do you drink alcohol? If “Yes”, how much in a typical week?......
1 unit = ½ pint beer. 1 unit = 1 small glass wine. 1 unit = 1 pub measure spirits.
11.Are you taking any prescribed medicines?
If “Yes”, give details ……………………………………………………………………………..
12. Have you ever been advised to refrain from driving on health grounds?

If you have answered “Yes” to any of questions 1-12, please give brief details

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DECLARATION

I declare that the responses I have given on this form are true to the best of my knowledge and belief.

Signature: ……………………………………………………………………. Date: ………………………………………….

Processed in accordance with the Data Protection Act 1998

The University of Strathclyde is a charitable body, registered in Scotland, with registration number SC015263