Duty of care

An Annual Driving Health Declaration

Driving Health Declaration

A    PERSONAL DETAILS
Surname: Date of Birth:
Forenames: Tel No (inc code):
Address1:
Address2:
Address3:
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
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.I   understand I must inform you immediately if my state of health and condition   alters from that stated above, any time after the date of this declaration.
Signature:                                                                   Dept:Full Name                                                                    Date:

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