DVLA Medical Questionnaire

Transcription

1 DVLA Medical Questionnaire Your Name: DOB: Today s Date:

2 Contents Introduction Key Client Information Important notes Vision assessment Health questionnaire Nervous system Diabetes mellitus - Blood sugar Psychiatric illness - nerves Heart health Coronary artery disease - chest pains Peripheral arterial disease excluding Buerger s disease), aortic aneurysm/dissection Valvular/congenital heart disease Other heart problems Heart investigations Blood pressure General health Additional information Declaration About CountryHealth 2

3 Introduction Thank you for choosing us to arrange your DVLA medical examination. In order to help us complete the official forms, please answer all questions to the best of your knowledge and believe. 3

4 Key Client Information Your Name Address Post code DOB Daytime tel. no. address Date first licensed to drive a lorry Date first licensed to drive a bus NHS GP Name NHS GP Address Important notes Please bring with you copies of relevant hospital notes. Please bring with you details of all current medication. 4

5 Vision assessment Please make sure to see an optician / optometrist FIRST and let them complete the first part of the medical examination report (D4). Please check that all questions have been answered and that the form has been signed, stamped and dated. Health questionnaire Please put a tick next to each question that applies to you and provide further information at the end of the questionnaire. Nervous system Is there a history of, or evidence of any neurological disorder? Have you had any form of seizure? Are you currently on anti-epileptic medication? Have you had a brain scan? Have you had an EEG? Have you had a Stroke or TIA? Have you made a full recovery? Has a carotid ultrasound been undertaken? Have you had a sudden and disabling dizziness/vertigo within the last year with a liability to recur? Have you had a subarachnoid haemorrhage? Have you had a serious traumatic brain injury within the last 10 years? Have you had any form of brain tumour? Have you had any other brain surgery or abnormality? Do you suffer from any chronic neurological disorder? Do you have Parkinson s disease? Is there a history of blackout or impaired consciousness within the last 5 years? Do you suffer from narcolepsy? 5

6 Diabetes mellitus - Blood sugar Do you have diabetes mellitus? Do you take Insulin? Do you take a Sulphonylurea or a Glinide? Do you take oral hypoglycemic agents and diet? Do you treat your diabetes with diet only? Do you test blood glucose at least twice every day? Do you test at times relevant to driving? Do you keep fast acting carbohydrate within easy reach when driving? Do you have a clear understanding of diabetes and the necessary precautions for safe driving Is there any evidence of impaired awareness of hypoglycaemia? Is there a history of hypoglycaemia in the last 12 months requiring the assistance of another person? Do you suffer from a loss of visual field? Do you suffer from severe peripheral neuropathy, sufficient to impair limb function for safe driving? Have you had laser treatment or intravitreal treatment for retinopathy? Psychiatric illness - nerves Is there a history of, or evidence of, psychiatric illness, drug/alcohol misuse within the last 3 years? Have you suffered from a significant psychiatric disorder within the past 6 months? Have you had a psychosis or hypomania/mania within the past 12 months, including psychotic depression? Do you suffer from dementia or cognitive impairment? Have you suffered from Persistent alcohol misuse in the past 12 months? Alcohol dependence in the past 3 years? Persistent drug misuse in the past 12 months? Drug dependence in the past 3 years? 6

7 Heart health Coronary artery disease - chest pains Is there a history of, or evidence of, coronary artery disease? Have you suffered from angina? Have you suffered from an acute coronary syndrome including myocardial infarction? Have you had a coronary angioplasty (P.C.I.)? Have you had a coronary artery bypass gra surgery? Cardiac arrhythmia - irregular heart beats Is there a history of, or evidence of, cardiac arrhythmia? Has there been a significant disturbance of your heart rhythm? i.e. sinoatrial disease, significant atrioventricular conduction defect, atrial flutter/fibrillation, narrow or broad complex tachycardia in the last 5 years? Has the arrhythmia been controlled satisfactorily for at least 3 months? Has a defibrillator (ICD) or biventricular pacemaker (CRT-D type) been implanted? Has a pacemaker been implanted? Are you free of the symptoms that caused the device to be fitted? Do you attend a pacemaker clinic regularly? Peripheral arterial disease excluding Buerger s disease), aortic aneurysm/dissection Is there a history of, or evidence of, peripheral arterial disease (excluding Buerger s disease), or aortic aneurysm/dissection? Do you suffer from peripheral arterial disease (excluding Buerger s disease)? Do you have claudication? Do you have an aortic aneurysm? Has it been repaired successfully? Is the transverse diameter currently > 5.5 cm? Has a dissection of the aorta been repaired successfully? Is there a history of Marfan s disease? 7

8 Valvular/congenital heart disease Is there a history of, or evidence of, valvular/congenital heart disease? Is there a history of congenital heart disease? Is there a history of heart valve disease? Is there a history of aortic stenosis? Is there any history of embolism? Do you currently have significant symptoms? Has there been any progression since the last licence application? (if relevant) Other heart problems Is there a history of, or evidence of heart failure? Do you have established cardiomyopathy? Has a le ventricular assist device (LVAD) been implanted? Have you had a heart or heart/lung transplant? Do you suffer from untreated atrial myxoma? Heart investigations Have any cardiac investigations been undertaken or planned? Has a resting ECG been undertaken? If YES, does it show:- pathological Q waves? le bundle branch block? right bundle branch block? Has an exercise ECG been undertaken (or planned)? Has an echocardiogram been undertaken (or planned)? If undertaken, is/was the le ejection fraction greater than or equal to 40%? Has a coronary angiogram been undertaken or planned? Has a 24 hour ECG tape been undertaken (or planned)? Has a myocardial perfusion scan or stress echo study been undertaken (or planned)? 8

9 Blood pressure Are you on anti-hypertensive treatment? If YES, please provide three previous readings with dates if available: 1. / on: 2. / on: 3. / on: General health Is there currently any functional impairment that is likely to affect control of the vehicle? Is there a history of bronchogenic carcinoma or other malignant tumour with a significant liability to metastasise cerebrally? Is there any illness that may cause significant fatigue or cachexia that affects safe driving? Are you profoundly deaf? If YES, Are you able to communicate in the event of an emergency by speech or by using a device, e.g. a textphone? Do you have a history of liver disease of any origin? Is there a history of renal failure? Is there a history of, or evidence of, obstructive sleep apnoea syndrome or any other medical condition causing excessive sleepiness? Do you have severe symptomatic respiratory disease causing chronic hypoxia? Does any medication currently taken cause you side effects that could affect safe driving? Do you have an ophthalmic condition? Do you have any other medical condition that could affect safe driving? Additional information Do you smoke: If yes, how many cig/oz per day: How many units of alcohol units to you consume each week? 9

10 Declaration I declare that I have checked the details I have given on the enclosed questionnaire and that, to the best of my knowledge and belief, they are correct. I understand that it is a criminal offence if I make a false declaration to obtain a driving licence and can lead to prosecution. Name: Signature: Date: 10

11 About CountryHealth Private GP Practice - We specialise in Thyroid Health and Functional / Nutritional Medicine Our patients usually get in touch when they need help that the NHS cannot provide. We can advise you on symptoms, organise specialist tests that are o en not available on the NHS and can also refer you privately to specialists. We want to find the root cause of your problems, not just cover the symptoms with medication. As a private medical patient, you can expect more personal, friendly consultations and appointments at times that suit YOU. To fully explore your concerns, we don t limit you to one problem per 10 minute appointment. Instead our appointments take typically minutes. Unfortunately, we cannot offer A&E services. Our approach is different. We want to find the root cause of your problems, not just cover the symptoms with medication. We offer a range of services to our clients to help them to Get Well and Stay Well. Health Screenings Genetic Testing Nutritional / Functional Therapy Food Intolerance Testing Bowel Cancer Screening To find out more, please visit our website: Practice: CountryHealth Cornwallis Chambers 23 Great Colman Street Ipswich IP4 2AN Phone : reception@countryhealth.co.uk 11