Health Assessment For Fitness To Drive
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3IN-CONFIDENCE WHEN COMPLETED
THIS FORM SHOULD BE RETAINED BY THE EXAMINING DOCTOR
Health Assessment for Fitness to Drive
CLINICAL ASSESSMENT RECORD
Driver information:
Surname:
Given name(s):
Address:
Date of birth:
Phone:
Driver licence number:
State of issue:
Employer information:
Employer name:
Address:
Phone:
Nature of driving duties:
CLINICAL ASSESSMENT:
1.
Vision
1.1 Visual acuity (refer AFTD, page 119)
Are glasses or contact lenses worn?
Yes
No
R
L
Both
Without Correction
6 /
6 /
6 /
With Correction
6 /
6 /
6 /
Meets criteria
Without correction
With correction
Does not meet criteria
1.2 Visual Fields
Normal
Abnormal
(refer AFTD, page 120)
Comments:
2.
Hearing (refer AFTD, page 64)
Are hearing aids worn?
Yes
No
Hearing level at frequencies (db)
Average of
0.5kHz
1.0kHz
1.5kHz
2.0kHz
3.0kHz
4.0kHz
6.0kHz
8.0kHz
0.5,1,2,3 kHz
Right ear
Left ear
Meets criteria
Without hearing aid
With hearing aid
Does not meet criteria
Comments:
Clinical Assessment Record – Page 1 of 3
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Parent category: Medical