MEDICAL CERTIFICATE ASSOCIATED WITH AN APPLICATION FOR A LICENCE TO DRIVE A HACKNEY CARRIAGE OR PRIVATE HIRE VEHICLE. Full name:... Date of Birth...

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1 NEWCASTLE CITY COUNCIL Regulatory Servces and Publc Protecton Envronment and Regeneraton Drectorate, Cvc Centre,Newcastle upon Tyne,NE1 8PB Tel: (0191) ; Fax: (0191) ; Emal: MEDICAL CERTIFICATE ASSOCIATED WITH AN APPLICATION FOR A LICENCE TO DRIVE A HACKNEY CARRIAGE OR PRIVATE HIRE VEHICLE Applcant s detals: (please complete) Full name:... Date of Brth... Current address: Applcant s consent and declaraton: (Please read the followng carefully before sgnng and datng the declaraton). I authorse my General Practtoner(s) and Specalst(s) to release medcal nformaton about my condton, together wth any relevant nformaton relevant to ftness to drve, to the Lcensng Secton, Newcastle Cty Councl for the purpose of the Councl (by ts Offcers and/or Members) of assessng my ftness to drve a hackney carrage prvate hre vehcle lcensed by that Councl. I declare that to the best of my knowledge and belef all nformaton gven by me to my doctors n connecton wth the examnaton or the completon of the DVLA Group 2 medcal examnaton report are true. In the event that the Councl s not satsfed of my ftness to drve a hackney carrage or prvate hre vehcle, I confrm that I may, at my own cost, submt such further medcal evdence to the Councl as I consder approprate. Sgned:... Date:... TO THE G.P. Ths form must be completed n full by the applcant s own G.P. or a medcal practtoner who has revewed the applcant s medcal records. Please answer all questons and once completed sgn the declaraton at the end. The Councls polcy on medcal ftness requres that tax drvers meet Group 2 Enttlement, as set out n the DVLA publcaton A Gude to the current Medcal Standards of Ftness to Drve. Ths gude makes reference to current best practce gudance contaned n the booklet Ftness to Drve whch recommends the medcal standard appled by DVLA n relaton to bus and lorry drvers should also be appled by local authortes to tax drvers. Is the applcant a regstered patent of the surgery / medcal centre at whch you practce as a regstered medcal practtoner? Have you revewed the above applcant s medcal records? 1. VISION: Is the vsual acuty at least 6/9 n the better eye and at least 6/12 n the other? (correctve lenses may be worn) (as measured wth the full sze 6m Snellen chart) Do correctve lenses have to be worn to acheve ths standard? If yes, s the: Uncorrected acuty at least 3/60 n the rght eye? 1 Drv. Appl

2 Uncorrected acuty at least 3/60 n the left eye? (3/60 beng the ablty to read the 6/60 lne of the full sze 6 metre Snellen chart at 3 metres) (c) Correcton well tolerated? Please state the vsual acutes of each eye n terms of the 6 metre Snellen chart. (Please convert any 3 metre readngs to the 6 metre equvalent) Uncorrected Corrected (f applcable) Rght Left Rght Left v Is there a defect n the patent s bnocular feld of vson (central and/or perpheral)? v Is there dplopa (controlled or uncontrolled)? v Does the patent have any other ophthalmc condton? If to questons 4, 5 or 6 please gve detals n Secton 8 and enclose any relevant vsual feld charts or hosptal letters. 2. NERVOUS SYSTEM Has the patent had any form of epleptc attack? If please answer questons a f below. Has the patent had more than one attack? Please gve date of frst and last attack: 1 st attack... Last attack... (c) Is the patent currently on ant-eplepsy medcaton? If please gve detals of current medcaton: (d) If treated, please gve date when treatment ended: (e). Has the patent had a bran scan? If please state dates and supply reports f avalable. (f) MRI CT Has the patent had an EEG? If please provde date and supply reports f avalable:. Is there a hstory of blackout or mpared conscousness wthn the last 5 years? If please gve dates and detals at Secton 8: Is there a hstory of, or evdence of, any of the condtons lsted at a g below? 2 Drv. Appl

3 If go to Secton 3. If please answer the followng questons, gve dates and full detals and supply any relevant reports. Stroke / TIA (please delete as approprate) If please gve date: Has there been a full recovery? Sudden and dsablng dzzness/vertgo wthn the last one year wth a lablty to recur (c) Subarachnod haemorrhage (d) Serous head njury wthn the last 10 years (e) Bran tumour, ether bengn or malgnant, prmary or secondary (f) Other bran surgery/abnormalty (g) Chronc neurologcal dsorders e.g. Parknson s dsease, Multple Scleross 3. DIABETES MELLITUS Does the patent have dabetes melltus? If please go to Secton 4. If please answer the followng questons. Is the dabetes managed by:- Insuln? If please gve date started on nsuln:... Exenatde/Byetta? (c) Oral hypoglycaemc agents and det? If please provde detals of medcaton: (d) Det only? Does the patent test blood glucose at least twce every day? v Is there evdence of:- Loss of vsual feld? Severe perpheral neuropathy, suffcent to mpar lmb functon for safe drvng? (c) Dmnshed / Absent awareness of hypoglycaema? v v Has there been any laser treatment for retnopathy? If please gve date(s) of treatment Is there a hstory of hypoglycaema durng wakng hours n the last 12 months requrng assstance? If to any of 4 6 above please gve detals n Secton 8. 3 Drv. Appl

4 4 PSYCHIATRIC ILLNESS Is there a hstory of, or evdence of any of the condtons lsted at 1 7 below? If please go to Secton 5. If please answer the followng questons and gve date(s), prognoss, perod of stablty and detals of medcaton, dosage and any sde effects n Secton 8. (Please enclose relevant notes). (If patent remans under specalst clnc(s) please gve detals n Secton 8). Sgnfcant psychatrc dsorder wthn the past 6 months? A psychotc llness wthn the past 3 years, ncludng psychotc depresson? Dementa or cogntve mparment? v Persstent alcohol msuse n the past 12 months? v Alcohol dependency n the past 3 years? v Persstent drug msuse n the past 12 months? v Drug dependency n the past 3 years? 5 CARDIAC Is there a hstory of, or evdence of, Coronary Artery Dsease? If please go to Secton 5B If please answer all questons below and gve detals at Secton 8 of the form and enclose relevant hosptal notes. 5A CORONARY ARTERY DISEASE Acute Coronary Syndromes ncludng Myocardal Infarcton? If please gve date(s):... Coronary artery by-pass graft surgery? If please gve date(s):... Coronary Angoplasty (P.C.I.)? If please gve date of most recent nterventon: v... Has the patent suffered from Angna? If please gve the date of the last attack:... Please go to next Secton 5B 5B CARDIA ARRHYTHMIA Is there a hstory of, or evdence of, cardac arrhythma? 4 Drv. Appl

5 If, go to Secton 5C If please answer all questons below and gve detals n Secton 7 of the form Has there been a sgnfcant dsturbance of cardac rhythm?.e. Snoatral dsease, sgnfcant atro-ventrcular conducton defect, atral flutter/fbrllaton, narrow or broad complex tachycarda n last 5 years? Has the arrhythma been controlled satsfactorly for at least 3 months? Has an ICD or bventrcular pacemaker (CRST-D type) been mplanted? v Has a pacemaker been mplanted? If : Please supply date:... Is the patent free of symptoms that caused the devce to be ftted? (c) Does the patent attend a pacemaker clnc regularly? Please go to next Secton 5C 5C PERIPHERAL ARTERIAL DISEASE (EXCLUDING BUERGER S DISEASE) AORTIC ANEURYSM/DISSECTION Is there a hstory or evdence of ANY of the followng: If go to Secton 5D. If please answer the questons below and gve detals n Secton 7 of the form. Perpheral Arteral Dsease (excludng Buerger s Dsease) Does the patent have claudcaton? If please gve detals as to how long n mnutes the patent can walk at a brsk pace before beng symptom lmted Aortc Aneurysm If : Ste of Aneurysm (please tck): Thoracc Abdomnal Has t been repared successfully? (c) Is the transverse dameter currently >5.5 cms? If please provde latest measurement:. Date obtaned: v Dssecton of the Aorta repared successfully If please provde copes of all reports to nclude those dealng wth any surgcal treatment. Please go to next Secton 5D 5D VALVULAR/CONGENITAL HEART DISEASE Is there a hstory of, or evdence of, valvular/congental heart dsease? If go to Secton 5E If please answer all questons below and gve detals n Secton 7 of the form 5 Drv. Appl

6 Is there a hstory of congental heart dsorder? Is there a hstory of heart valve dsease? Is there any hstory of embolsm? (not pulmonary embolsm) v Does the patent currently have sgnfcant symptoms? v Has there been any progresson snce the last lcence applcaton? (f relevant) 5E CARDIAC OTHER Does the patent have a hstory of ANY of the followng condtons: If go to Secton 5F If please answer all questons below and gve detals n Secton 7 of the form A hstory of, or evdence of, heart falure? Establshed cardomyopathy? (c) A heart or heart/lung transplant? 5F CARDIAC INVESTIGATIONS (Ths secton must be flled n for all patents) (Please provde relevant reports) Has a restng ECG been undertaken? If does t show: Pathologcal Q waves? Left bundle branch block? (c) Rght bundle branch block? Has the exercse ECG been undertaken (or planned)? If please provde date and gve detals n Secton 8:... Has an echocardogram been undertaken (or planned)? If please gve date and gve detals n Secton 8:... If undertaken s/was the left ventrcular ejecton fracton greater than or equal to 40%? v Has a coronary angogram been undertaken (or planned)? If please provde date and gve detals n Secton 8:... v Has a 24 hour ECG tape been undertaken (or planned)? If please provde date and gve detals n Secton 8:... v Has a Myocardal Perfuson Scan or Stress Echo study been undertaken (or planned)? If please provde date and gve detals n Secton 8:... 6 Drv. Appl

7 Please go to next Secton 5G 5G BLOOD PRESSURE (Ths secton must be flled n for all patents) Is today s best systolc pressure readng 180mm Hg or more? (Please gve readng) (BP readng:...) Is today s best dastolc pressure readng 100mm Hg or more? (Please gve readng) (BP readng:...) Is the patent on ant-hypertensve treatment? If to any of the above please provde three prevous readngs wth dates f avalable: 1. B.P readng:.. 2. B.P readng:.. 3. B.P readng: Date:... Date:... Date: GENERAL (Please answer all questons n ths secton. If your answer s to any queston please gve full detals n Secton 8. Is there currently a dsablty of the spne or lmbs lkely to mpar control of the vehcle? Is there a hstory of bronchogenc carcnoma or other malgnant tumour, for example, malgnant melanoma, wth a sgnfcant lablty to metastasse cerebrally? If please gve dates and dagnoss and state whether there s current evdence of dssemnaton? Is there any evdence the patent has a cancer that causes fatgue or cachexa that affects safe drvng? Is the patent profoundly deaf? If s the patent able to communcate n the event of an emergency by speech or by usng a devce e.g. a textphone? v Is there a hstory of ether renal or hepatc falure? v Is there a hstory of, or evdence of sleep apnoea syndrome? If please provde detals: Date of dagnoss: 7 Drv. Appl

8 Is t controlled successfully? (c) If please state treatment:... (d) Please state perod of control:... (e) Please provde neck crcumference.. (f) Please provde grth measurement n cm... (g) Date last seen by consultant... v Does the patent suffer from narcolepsy/cataplexy? v Is there any other Medcal Condton causng daytme sleepness? If please provde detals: Dagnoss: Date of dagnoss: (c) Is t controlled successfully? (d) (f) If please state treatment: (e) Please state perod of control Date last seen by consultant: v Does the patent have severe symptomatc respratory dsease causng chronc hypoxa? x Does any medcaton currently taken cause the patent sde effects that could affect safe drvng? If please provde detals: x Does the patent have any other medcal condton that could affect safe drvng? If please provde detals: ALCOHOL AND/OR DRUG MIS-USE (Please answer all questons n ths secton. If your answer s to any queston please gve full detals n Secton 8. Does the patent show any evdence of beng addcted to excessve use of alcohol? Does the patent show any evdence of beng addcted to excessve use of drugs? 8 Drv. Appl

9 8. Please forward copes of relevant hosptal notes only. PLEASE DO T send any notes not related to ftness to drve GP S DECLARATION: Please read the followng carefully before completng, sgnng and datng the declaraton. If the applcant/patent s not a regstered patent wth your practce or you have not revewed hs/her medcal records then do not complete the declaraton. I certfy that I am famlar wth the current requrements of Group 2 medcal standards appled by the DVLA n the current verson of Medcal Standards of Ftness to Drve. I certfy that I have revewed the applcant s medcal records and that n my opnon nothng theren contradcts or tends to contradct the nformaton gven to me by the applcant. I certfy that I have today undertaken a medcal examnaton of the applcant for the purpose of assessng ther ftness to act as a drver of a Hackney Carrage or Prvate Hre drver under the DVLA Group 2 medcal standards I certfy that havng regard to the foregong, the applcant * MEETS / DOES T MEET (*delete as approprate) the mnmum standards requred for the DVLA Group 2 medcal standards. Doctor s name: Surgery Stamp: Surgery name: Surgery address: Sgned: Date: 9 Drv. Appl