or Service SA Centre, or mailed to PO Box 1, Walkerville SA 5081 Telephone Enquiries: 13 10 84 Additional Comments www.dtwww.sa.gov.auei.sa.gov.au - ABN - ABN 92 36692 3 28866 288 135 135 MR 713 www.dtei.sa.gov.au - ABN 92 3FOLD 66 288MayMay 135 bebe lodglodgeded at at any any RServiceegistration SA Centre,and Licen or smaileding Centr toe 08/06
SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD May be lodged at any Registration andorGPO L Seicenr viceBoxsing SA 1533,Centr Centre, eAdelaide or mailed SA 5001to PO Box 1, Walkerville SA 5081 (see also MR215A) ...... or Service SA Centre, or mailed to POCERTIFIC Box 1, Walkerville SA 5081 ATE OF FITNESS - Under section 148 of the Motor Vehicles Act 1959 you have a legal obligation to inform the Registrar of Motor Vehicles if CERTIFICATEwww.dtTewww.sa.gov.auTelelep phonhoenei.sa.gov.aue Enqui Enquiries: -rie ABN s:- ABN1 133 92 10 10 36692 84 84 OF3 28866 288 135 FIT 135 NESS MR 713 you have reasonable cause to believe Additionalthat your Comments patient is suffering from a physical or mental illness, disabilityTe orle phone Enquiries: 13 10 84 Government (see also MR215A) www.dtei.sa.gov.au - ABN 92 3FOLD 66 288 135 MR 713 LMPR08/06 Additional Comments ...... MayMay bebe lodglodgeded at at any any RServiceegistration SA Centre,and Licen or smaileding Centr toe of South Australia
SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD deficiency that is likely to endanger the public if your patient drives a motor vehicle. May be lodged at any Registration andHEAVorGPO L Seicenr viceBoxsing SA 1533,Centr Centre, eYAdelaide oVEHICLEr mailed SA 5001 to PO Box 1, Walkervi DlleRIVER SA 5081 08/06S (see also MR215A) ...... LIGCERTIFICHT VEHICLAETE (PRIVATE) OF FITNE DRIVER(see alsoSS MR215A) -S Department of Planning, Under section 148 of the Motor Vehicles...... Act 1959 you have a legal obligation to inform the Registrar of Motor orVehicles Service SA if Centre, or mailed to PO Box 1, Walkerville SA 5081 If you consider...... it prudent you may recommend that your patient undertakes a practical driving assessment. This is irrespectiveCERTIFIC of your ATECERTIFICATETeTelele p pOFhonhonee Enqui Enquiries: FITNEries: 1 133 10 10 84 84OFSS FIT - NESS Transport and Infrastructure you have reasonable cause to believe Additionalthat your Comments patient is suffering from a physical or mental illness, disabilityTe orle phone Enquiries: 13 10 84 LMPR Government (see also MR215A) patient’sAdditional age or Commentsdriver’s licence class...... MR 713 deficiency that is likely to endanger the...... public if your patient drives a motor vehicle. LICENCEHEAVY CLASSES VEHICLE C, RDATE, DRIVER LMPRR,08/06 LRS of South Australia HEAVY VEHICLELIGHT VEHICDRIVERLE (PRIVATE)S DRIVER(see also MR215A) S ...... CERTIFICATE OF FITNESS - Department of Planning, ...... If you consider...... it prudent you may recommend that your patient undertakes a practical driving assessment. This is irrespectiveCERTIFIC of your ATE OF FITNESS - CLIENT No. (This is your Driver’s Licence Number) Transport and Infrastructure patient’s age or driver’s licence class...... HEAVY VEHICLELICENCEHEAV DY RIVERCLASSES VEHICLES C, RDATE, DRIVER LMPRR, LRS
...... Driver’s Licence No: If you consider that your patient may be unfit...... to drive, please immediately return the completed certificate to CLIENT No. (This is your Driver’s Licence Number) ...... CLIENT No. (This is your Driver’s Licence Number) Locked Bag 700, Adelaide SA 5001. Information may be immediately faxed to 8402 1977...... WHO NEEDS TO COMPLETE THIS FORM? CLIENTWHAT No. YOU (ThisDriver’s W isILL your NEED Driver’s Licence TO DLicenceO Number)No: IfIt youis recommended consider that thatyour you patient keep may a copy be unfitof...... this to form drive, for please your immediatelyown records. return the completed certificate to Class of Licence: ...... CLIENT No. (This is your Driver’s LicenceTO O Number)BTAIN/RETAIN YOUR DRIVER’S LICENCE, YOU ARE Locked Bag...... 700, Adelaide SA 5001. Information may be immediately faxed to 8402 1977. Any person who drives a motor vehicle with a GVM exceeding ...... REQUIRED TO: ...... 8000kg and- MEDICAL...... PRACTITIONER’S DECLARATION WHO NEEDS TO COMPLETE THIS FORM? 1. Make an appoinWHATtme ntYOU with WILL you NEEDr reg ulTOar D trOeating doctor for a long It is recommended that you keep a copy of...... this form for your own records. Class of Licence: ...... WHO NEEDS TO COMPLETE THIS FORM? WHAT YOU WILL NEED TO DO (45minute) consultation. The cost of this consultation is// your ...... • Is aged 70 years or more TToO O obtain/retainBTAIN/RETAIN YOUyourR DDdriver’sRIDueVER’S’S licence,LICDate:ENCE, youYOU areAREARE required to: ...... Any person who drives aT Omoto OBTAIN/REr vehiclTAIe Nwith YOU aR GDRIVMVER ’Sex LICceeENdiCE,ng YOU AREQU REr esIpoREDns TO:ibility...... Any person who drives a motor vehicle with a GVM exceeding Make an appointment with your regular treating doctor for a long On I examined...... 8000kg and- REQUIRED TO: 2. Explain to your doctor the reason for the consultation. MEDICAL...... PRACTITIONER’S DECLARATION...... • Has a medicalWHO NEEDS condition TO COMP or LETdisabilityE THIS FOwhichRM? may affect (45 minute) consultation.WHAT YOU When WILL NEED making TO theDO appointment: (Date of Examination)...... (Patient’s name) 8000kg and- 1.3. MaCompke anlete app Secointionstme 1nt and with 2 ofyou thir sreg foulrmar be trforeeatin hgandi docntorg itfor to a yo longur ...... WHO NEEDS TO COMPLETE THIS FORM?or theirService ability SA to Centre, drive. or1. mailed Make an to app POoinWHAT Boxtme ntYOU 1 ,with Walkervi WILL you NEEDr reglle ulTO arSA D trO e5081ating doctor for a long // ...... TTo1.O( dOExplain 45obtain/retainoctor.BTmiAIN/REnu B te)theeTAI s ureconsulreasonN YOU yourto tatisign Rfor Ddriver’son.RI Due theSVEect T Rconsultation.’Sheion licence,LICDate: cos 2EN tin CofE, t hethyouYOUis p rcon areAREesen surequired cltatie ofon you isto: ry docour tor...... • AIsny aged pe rs70on years who ordrive mors ea moto(45mir vehiclnute) econsul with tatia Gon.VM T heex ceecosdit ofng this consultation is your ...... • Is aged 70 years or more www.dtTelephonei.sa.gov.aue Enquirie s:- ABN13TO 10 O BT92 84AIN/RE 366TAI 288N YOU 135R DRIVER’S LICENCE, YOU A REQU2.RE r CompleteesIpoREDns TO:ibil itysections. 1 and 2 of this form before handing it to your On I examinedAdditional Comments Any person who drives a motor vehicle withwww.sa.gov.au• Thea G VMlicence exce clasedin ses- ABNg that includ 92res 366poe tnshese ibil288 ityvehicle 135. s 4.Make Take an s peappointmentctacles, heari withng aid yours, the regular nam estreating of any doctormediMRc atiofor nsa 713long you
...... www.dtei.sa.gov.au - ABN 92 3FOLD 66 288 135 REQUIRED TO: 2. Explain to your doctor the reason for the consultation...... May • 8Has00 be0kg a medicallodg and-ed atcondition any R eorgistration disability andwhich L icenmay saffecting Centr e 2. mayEdoctor.xpl aiben cuBetorr ysureenoutlyr tod taoc signkitorng, Sectionthe et c.rea toson 2the in fo ctheron the supresence ltaticonsonultation. of your.08/06 doctor...... May be lodged at any Service SA Centre, or mailed to (45 minute) consultation. When making the appointment: SECTION...... 5: MEDICAL PRACTITIONER’S DECLARATION FOLD 2. Explain to your doctor the reason for the cons1. Maultatike onan. appointment with your regular treating doctor for a long This patient...... has been treated at this clinic for years months. May • 800Has be0k a glmedicalodg ande-d atcondition any R eorgistration disabilityWhat andwhich L toareicenmay MR;do saffecting withHR; Centr HC thee and completed MC. certificate 3. Complete Sections 1 and 2 of this form before handi(seen alsog it MR215A)to your (Date of Examination) (Patient’s name) orGPO theirSer viceBox ability SA 1533, to Centre, drive. Adelaide or1. mailed Ma SAke an 5001 to app POoin Boxtment 1 ,with Walkervi your reglleul arSA tr e50813.ati Takeng d octorspectacles, for a lonhearingg aids, the names of any medications you ...... CERTIFIC3. CompAleteTE Sections 1 OFand 2 of thi sFITNE form befo 1.r (deExplain45 octor.hamindinu ngB thete)e itSSs ureconsulreasonto yo tour tatisign for-on. theSect T consultation.heion cos 2 tin of t heth isp rconesensucltatie ofon you isr y docourt or. Under section 148 of the Motor Vehicles...... Act 1959 you have a legal obligation to inform the Registrar of Motor orVehicles theirService ability SA if to Centre, drive. or mailed to PO B• oxIs aged1, Wa 70lke yearsrvi orlle morSA e 508(451minute) consultation. The cost of this consul maytati beon currently is your taking, etc. to the consultation...... • Is aged 70 years or more CERTIFICATEorTeTele leSep prhonhovicenee SAEnqui Enquiries:IMPORTANT Centre,ries: 1o 13r3 mailedINFORMATION10d 10octor. 84 84OF Btoe POsure FIT TOBoxto signAPPLICANTS! 1, SNESWalkerviection 2 inOnlylleS the SA in pr exceptionalesenc 4.50812. rTaCompleteespoeke o nssfpe youibilc tacases ityrsectionscles, do. ct wouldheor ari.1 andng a aid person2 s,of thethis nwho formames has beforeof any handingmedicatio it nsto yoyouru you have...... reasonable cause to believe Additionalthat your Comments patient is suffering from a physical or mental illness, disabilityTe orle phone Enquiries: 13 10 84 • The licence classes that includ respoe tnsheseibil ityvehicle. s LMPR (see also MR215A) ...... • ReturnTe• Haslep honto a medical GPOe Enqui Box conditionrie 1533,s: 134. or 10AdelaideTa disability ke84 specta whichcles,5001 he may orari ng any affect aid Services, the nam SAes of Customer 2. any mayEdoctor. xpmel aibedinMRc cuatiBe tServiceorr ons ysureenou 713 tlyyour tod taoc Centresignkitorng, Sectionthe et c.rea toson 2the in fo ctheron the supresence ltaticonsonultation. of your. doctor. Additional Comments ...... • The licence classes that include these vehiclewww.dtwww.sa.gov.auepilepsys ei.sa.gov.au or diabetes - ABN - controlled ABN2. 92 Exp 36692lai 3nby 288 6t o6oral y288ou 135 medicationr d 1oc35tor the orrea insulinson for tbehe consideredconsultation for. a licence to drive a heavy vehicle. If youMR 713 deficiencyThisIn my patient opinion...... thathas the been is person likely treated whoto endangerat is thisthe clinicsubject the Additionalfor...... of public this Comments report: if your patient years drives a motor months. vehicle. • Has a medical condition or disabilityWhat whichHEAV toaremay MR;do affect withHR; HC theY and completed VEHICLEMC may. be curr encertificatetly taking, etc. t o Dthe conRIVERsultati3. onConot.mp responsiblelete08/06 SectiSons for 1the and cost 2 ofof thithes foconsultation.rm before handing it to your FOLD www.dtei.sa.gov.au - ABN 92 3FOLD 66 288 135 3. Take spectacles, hearing aids, the names of any medications you ...... LIGMayMay their H bebe ability lodglodgedThave e toVEHICd at drive.eitherat any any of RService3. thesee gistrationCompL conditions SAleEte S Centre,andec(PRIVATE)tions itL mayicen 1 orand sbemaileding 2 preferableof Centr thi sto foerm to befo have DRIVERre hayourn(seedi ngtreating also it MR215A)to yo specialistur S physician conduct 08/06 ...... are MR; HR; HC and MC. doctor. Be sure to sign Section 2 in the presence of your doctor. FOLD SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD CERTIFICATE OF FITNESS - ...... May their be ability lodge tod atdrive. any Registration• andEnquiries: Licensing 13 Centr 10 84e (see also MR215A) ...... CERTIFICATEor Se OFrvice SA Centre,FITNE or maileddoctor. Btoe POSSsure Boxto sign - 1, SWalkerviection 2 inlle the SA pr esenc5081 maye o bef you currentlyr doctor taking,. etc. to the consultation. If you consider...... it prudent you may recommend...... that your patient undertakes a practical driving assessment. This is irrespective of your GPO BoxIMPO 1533,IMPORTANTRTAN AdelaideT IN FOINFORMATION RMSA AT5001IOtheN examination TO TO APPLICANTS! APPLIC inAN order OnlyTS! to Only in avoid exceptional4. inTa twoexceptionalke s consultations.pec tacasescles, cases wouldheari wouldng a aid person s,a theperson nwhoam whoes has of hasany amedi cardiaccatio ns you ...... or Service SA Centre, or mailed to POCERTIFIC B• oxThe 1 ,licence Walke clasrviseslle that SA includ5081e AtheseTE vehicles OF FITNESS - Under section 148 of the Motor Vehicles...... Act 1959 you have a legal obligation to inform the Registrar of Motor Vehicles ifIMPORTANT INFORMATION• CERTIFICATEReturn TeTOTelele APPLICANTS!p p hontoho neGPOe Enqui Enquiries: Box Onlyrie 1533,s: in 1 exceptional1334. 10AdelaideTa 10 ke84 84 OFspec tacases cles,5001 FIT wouldhe orari ng any NESa aid person Services, the nwhoamS SAes has of Customer anymay me bedic cuati Servicerronsen tlyyou ta Centreking, etc. to the consultation. patient’sMeets the age relevant or driver’s medical licence standard class...... Yes No • The licence classes that include these vehicleepilepsys condition, or diabetes epilepsy controlled or diabetes by controlled oral medication by oral ormedication insulin be or considered insulin beLMPR forconsidered a licence for to drivea licence a heavy to drive vehicle. a heavy If you vehicle. In my opinion the person who is the subjectAdditional...... of this Comments report: Telephone Enquiries: 13 10 84 LICENCEHEAVSECTION are MR; 1: HR; - YOUR HCY andDETAILS.CLASSES VEHICLEMC may. Please be curr enwritetly ta clearlyki ng,C, et c. using RDATE,t o Dthe BLOCK conRIVERsultati LETTERS onnot. responsible R, LRS for the cost of the consultation. (see also MR215A) you have...... reasonable cause to believe that...... your patient is suffering from a physical or mental illness, disability orepilepsy or diabetes controlled by oral medication or insulin be considered for a licence to drive a heavy vehicle. If youMR 713 LMPR Government If no, pleaseAdditional...... provide Comments details below: ...... HEAV are MR; HR; HCY and VEHICLEMC. If you havehave Dany either ofRIVER these of these conditions conditions it mayS it maybe preferable be preferable to have to haveyour treatingyour treating specialist specialist physician physician conduct conduct the examination in deficiency that is likely to endanger the public if your patient drives a motor vehicle. have either of these conditions• Enquiries:HEAV it may be 13 preferable 10 84Y to haveVEHICLE your treating specialist(to be physician completed D RIVERconduct in BLOCK08/06S letters prior to seeing your doctor) of South Australia ...... SECTION 1: YOUR DETAILS CLIENT No. (This is your Driver’s Licence Number) ...... LIGHIMTPO VEHICIMPORTANTRTANT IN FOINFORMATIONRMLATEIOthe (PRIVATE)N examination TOTO APPLICANTS! AorderPPLIC intoAN orderavoid OnlyTS! to twoOnly in avoid exceptionalconsultations. DRIVERin twoexceptional(see consultations. also cases MR215A) cases would wouldS a person a person who who has has a cardiac ...... CERTIFICATE OF FITNESS - Department of Planning, Please...... answer the following questions Yes / No IMPORTANT INFORMATIONthe examination TOSURNAME APPLICANTS! in order Only to in avoid exceptional two consultations. cases would a person who has If Meetsyou consider the...... relevant it prudent medical you standard may recommend that your patient undertakesYes a practical driving No assessment. This is irrespectiveCERTIFIC of your ATEepilepsy condition,OF or diabetes epilepsyFITNE controlled or diabetes by controlled oralSS medication by- oral ormedication insulin be or considered insulin be forconsidered a licence for to adrive licence a heavy to drive vehicle. a heavy If you vehicle. Transport and Infrastructure ...... SECTION 1: - YOUR DETAILS. Please write clearly using BLOCK LETTERS ...... epilepsy or diabetes controlled by oral medication or insulin be considered for a licence to drive a heavy vehicle. If you patient’sIf no, please age...... or provide driver’s details licence below: class. In...... accordance with the National Transport Commission standards “Assessing Fitness to Drive”- SECTION 1: - YOUR DETAILS. PleaseSurname write clearlyIf you have usinghave any either BLOCK of these of theseLETTERS conditions conditions it may it maybe preferable be preferable to have to yourhave treatingyour treating specialist specialist physician physician conduct conduct the examination in ...... have either of these conditionsSECTIONLICENCEHEAV it GIVENmay beNAMES1: preferable YOURY CLASSESto haveVEHICLE DETAILS your treating specialist(to C, be physician completedRDATE, D RIVERconduct in BLOCK LMPRR, LRS letters prior to seeing your doctor) ...... CLIENT No. (ThisDriver’s is your Driver’s Licence Licence Number)No: If you consider that your patient may be unfitDo...... you to cnsider drive, the applicant please medically immediately and psychologically return fit to drive the a heavycompleted commercial vehicle?certificate to HEAVY VEHICLE DRIVERthe examinationS order into orderavoid totwo avoid consultations. two consultations...... Please answer the following questions Yes / No Giventhe examination namesSURNAME in order to avoid two consultations.CLIENT No. (This is your Driver’s Licence Number) Date of birth MR712 09/20 LockedPatients Bag who...... 700, hold Adelaide a licence SA other 5001. than Information a “car” licence may beare immediately required to faxedundergo to 8402a practical 1977. driving assessment at age 85 and everySURNAME year CLIENT No. (This is your Driver’s Licence Number) PleasePlease answer answer the followingthe following questions questions Yes / No Yes / NoIf ...... ‘No’, do you consider the applicant medically and psychologically fit to drive a light vehicle? SECTION 1: - YOUR DETAILS. Please write clearly using BLOCK LETTERS ...... HOME ADDRESS thereafter...... to retain the additional licence Inclass. accordance with the National Transport Commission standards “Assessing Fitness to Drive”- SECTION 1: - YOUR DETAILS. PleaseSurname write clearly using BLOCK LETTERS In...... accordance with the National Transport Commission standards “Assessing Fitness to Drive”- Home GIVENaddress NAMES In accordance with the National Transport CommissionDo standards you consider “Assessing that it Fitness is prudent to Drive”- or necessary for the applicant to undergo a practical driving assessment? GIVEN NAMESWHO NEEDS TO COMPLETE THIS FORM? WHAT YOUDAYTIME WILL NEED TO DO It is recommended that you keep a copy ofDo...... thisyou cnsider form the forapplicant your medically own and records. psychologically fit to drive a heavy commercial vehicle? GIVEN NAMES Class of Licence: Please...... answer the following questions Yes / No ______Given namesSURNAMESUBURB/TOWN POSTCODETO OBTAIN/RETAIN YOUR DPHONERIVER’S No. LICDateENCE, YOUof AREbirth Do...... you cnsider the applicant medically and psychologically...... fit to drive a heavy commercial vehicle? Any person who drives a motor vehicle with a GVM exceeding CLIENT No. (ThisDriver’s is your Driver’s Licence Licence Number)No: If you considerPleasePlease answer answer that the following theyour following patientquestions questions Yes may / No Yesbe /unfit NoIfNOTE ...... ‘No’, : to doA practical youdrive, consider driving please the assessment applicant immediately medically cannot be and undertaken psychologically return if the theapplicant fit to completed drive is considereda light vehicle? to certificate be medically or psychologicallyto unfit to drive.SURNAME Suburb/Town PostcodeREQUIRED TO: Daytime phone no ...... ______HOME ADDRESS CLIENT No. (This is your Driver’s Licence Number) If ‘No’, do you consider the applicant medically and psychologicallyIn...... accordance fit with to drivethe National a light vehicle? Transport Commission standards “Assessing Fitness to Drive”- MEDICALLocked Bag...... PRACTITIONER’S 700, Adelaide SA DECLARATION5001. Information may be immediately faxed to 8402 1977. HOME ADDRESS 8000kg and- InInDo accordance accordance you consider with with the that National the it Nationalis Transportprudent Transport Commission or necessary CommissionDoIf standards...... recommending you for consider the “Assessing applicant standardsthat a practical it Fitness is prudentto driving“Assessing undergoto Drive”- or assessment, necessary a Fitness practical for please the to applicantdrivingDrive”-note in the toassessment? spaceundergo below a practical any particular______driving factors assessment? in relation to this patient that the Driving Assessor should be made Home addressGIVENPOSTAL NAMES WHOADDRESS NEEDS (If di erent TO COMP fromLET above)E THIS FORM? 1. Make an appoinWHATtment YOUwith WILLyour NEED reg ulTOar D trOeating doctor for a long ...... GIVEN NAMES DAYTIME Do...... you consider that it is prudent or necessary for the applicantDo...... you cnsider to undergo the applicant a practical medically driving assessment?and psychologically fit to drive a heavy commercial vehicle? WHO NEEDS TO COMPLETE THISPostal FORM? address if different from aboveWHAT YOU WILL NEED TO DO (45minute) consultation. The cost of this consultation is// your RequiresDo youa practical cnsider the applicant driving medically test and psychologicallyaware...... fit of to (eg.drive limb a heavy mobility, commercial concentration vehicle? span, etc). Yes No ______• SUBURB/TOWNIs agedWHO 70 years NEEDS or TmorO COMPe LETE THIS FORM? DAYTIME POSTCODETToO O obtain/retainBTAIN/RETAINWHAT YOUyourR DYOUdriver’sPHONERIDueVE WR’SILL No. licence,LICDate: NEEDENCE, TO you YOU DO areARE required to: It is recommended...... that you keep a copy of...... this form for your own records. SUBURB/TOWN Suburb/TownARE Any YOU pers CURRENTLY on who drivePOSTCODE BEINGs aTOmoto OTREATEDBTAIN/REr vehicl TAIBYe NwithANY YOU OTHERaR GDPHONERIVMVE RDOCTOR ’Sex No. LICceeENdiCE,ng OR YOU SPECIALIST Postcode ARErespons FOR ibil ityANY. REASON?Class Daytime of Licence: phoneYES no NO NOTE: A practical driving assessment cannotIfNOTE ...... ‘No’, be : undertakendoA practical you consider driving if the the assessment applicant applicant medicallycannot is considered be and undertaken psychologically to if bethe medicallyapplicant fit to drive is consideredora light psychologically ______vehicle? to be medically or psychologically unfit to drive. Any person who drives a motor vehicle withHOME a GVM ADDRESS exceeding TREQUMakeO OBTIRED AIN/REan TO:appointmentTAIN YOUR withDRIVE yourR’S LIC regularENCE, YOU treating ARE doctor for a long On IfNOTE ...... ‘No’,: doA practicalyou consider driving the assessment applicant medically cannotI examined be and undertaken psychologically...... if the applicant fit to drive is considereda light vehicle? to be medically or psychologically unfit to drive. HOME ADDRESS Email• address 8AHas00ny0kg pea medicalrs ao nd-(ifn wh available) conditiono drives aREQU motoor disabilityIREDr vehicl TO: whiche with maya GVM affect exceeding 2. Explain to yourdoctorIn signing the rea thisson form youfort consenthe co tons yourul doctortation releasing. If ...... recommending a practical driving assessment, please note in the space below any particular factors in relation to this patient that the Driving Assessor should be made REQU(45 minute)IRED TO: consultation.to the WhenRegistrar ofmaking Motor Vehicles, the appointment:any medical information that Do...... you consider that it is prudent or necessaryDo...... you for consider the applicant that it is prudentto undergo or necessary a practical for the applicantdriving toassessment? undergo a practical ______driving assessment? 8000kg and- POSTAL ADDRESS (If di erent from above) 1.3.Ma Compke anlete appSecointionstme 1nt andDAYTIMEwith 2 ofyour this reg foulrmar be trforeeatin hgandi docntorg itforto a yolongur (Date ofDoIf Examination) recommending you consider that a practical it is prudent driving or assessment, necessary for please the applicantnote...... in the to spaceundergo below a practical any particular driving factors assessment? in relation to this patient(Patient’s that the Driving name) Assessor should be made POSTAL ADDRESS (If di erent from above)Postal address8their000kg ability and- if to different drive. 1. fromMake anabove appoin tment with your regular treating doctor for a longmay a ect your ability to drive safely. MEDICALRequires...... PRACTITIONER’Sa practical driving DECLARATIONtest aware...... of (eg. limb mobility, concentration span, etc). Yes No SUBURB/TOWN DAYTIME POSTCODE1. (dExplain45ocmitor.nuB thete)e s ureconsulreason to tatisign foron.PHONE theSect T consultation.heion No. cos 2 tin of t heth isprconesensucltatie ofon you isr y docourtor...... • Is agedWHO 70 years NEEDS or TmorO COMPe LETE THIS FORM? 1. Make an appoinWHATtment YOU with W ILLyourou NEEDr reg ulTOar D trOeating doctor for a long awareIf...... recommending of (eg. limb mobility, a practical concentration driving span, assessment, etc). please note in the space below any particular factors in relation to this patient SUBURB/TOWNWHO NEEDS TO COMPLETE THIS FORM?ARE YOU CURRENTLYPOSTCODE BEING( TREATED45minute) BY consul ANY tatiOTHERon.PHONE T DOCTORhe No. cost of OR thi SPECIALISTs consulrespotatins FORonibil is ityANY you. r REASON? YES NO NOTE: A practical driving assessment cannotNOTE...... be : undertakenA practical driving if the assessment applicant cannot is considered be undertaken to if bethe medicallyapplicant is consideredor psychologically to be medically or psychologically unfit to drive.• Is aged 70 years or more WHAT YOU WILL NEED TO DO 4.2. (TaComplete45kemi snupete)cta sections cles,consul hetati ari1 andngon.Due aid 2T hes,of Date:the this cos nt formamof thes isbeforeof conanysu handingmediltationcatio is//it y nstoour yoyour u NOTE: A practical driving assessment cannot be undertaken...... if the applicant is considered to be medically or psychologically unfit to drive. ARE YOU CURRENTLY BEING TREATED BY ANY• SIGNATUREIsThe OTHER agedlicence 70DOCTOR yearsclasses or OR thatmor SPECIALIST include respoe tns heseFORibil ityvehicleANY. REASON?s TToO O obtain/retainBTYESAIN/RE TAI NON YOUyourR InInDdriver’s DATERIsigningsigningVER ’Sthisthis licence,LIC formformEN...... /...... /...... youyouCE, consentconsent youYOU are AREtoto youryour required doctordoctor releasingreleasing to: ...... Email1. Have• address AHasny peayou medicalrso (ifnconsulted wh available) conditiono drives aanyT Omotoor O disabilityBT medicalAIN/REr vehiclTAI whiche Nwithpractitioner YOU mayaR GDRIVM affectVER ’Sex LIC ceewithinENdiCE,ng YOU the A2. RE last mayE doctor.xpl ai12ben cuBetmonthsorr ysureentlyourd totaoctor sign kithatng, Section the e thet c.rea toson medical 2the in fo cthertonhe supresence ltaticopractitionernsonultation. of your. doctor. completing this form does that the Driving Assessor should be made awareIf ...... recommending of (eg. limb a practical mobility, driving concentration assessment, please span, note etc). in the space below any particular factors in relation to this patient that the Driving Assessor should be made In signing this form you consent to REQU yourres doctorIpoREDns releasingTO:ibility. to the Registrar of Motor Vehicles, any medical information that ...... • AHasny pea medicalrson who condition drives a motoor disabilityr vehic lewhich withPOSTAL maya GVM affect ADDRESS exceedin (If di erentg 2. fromExp above)lain to yourdoctor the reason forthe cons3.Make Coultatimp anonle appointmentte. Sections 1 withand 2your of thi regulars form treating before doctor handin forg it at olong your ThisOn patientIf recommending has been a practical treated driving at assessment, thisI examined clinic please notefor...... in the space below any particular years factors in relation to this patient months. that the Driving Assessor should be made POSTAL ADDRESS (If di erent from above) What toare MR;do withHR; HC the and completed MCREQU. IRED TO: certificateto the Registrar of Motor Vehicles,2. 3.any ETake medicalxplai spectacles,n information to you rdrthat dhearingoctoroc tormay t a ect heaids, rea your theson ability namesfo tortr drivethe of safely.co anynsul medicationstation. you aware...... of (eg. limb mobility, concentration span, etc). not• 8Hastheir00 know0kg aability medical and- about? to drive.condition Please3. or Co providedisabilitymplete Sthe whichecti nameons may 1 andof affect medical 2 of this practitioner form befo(45red ochaorminute)tor.n treatingdingBe it consultation.s ureto specialist yo tour sign S Whenection making2 in the thepresen appointment:ce of your doctor. Do...... you recommend conditions be placed on ...... the applicants driver’s licence? ______8000kg and- may a ect your ability to drive safely.1.3. MaCo mpke anlete app Secointionstme 1nt and with 2 ofyourou thir s reg foulrmar be trforeeatin h gandi docntorg itfor to a yo longur (Date ofaware IfExamination) recommending of (eg. limb mobility, a practical concentration driving span, assessment, etc)...... please note in the space below any particular factors(Patient’s in relation name) to this patient their ability to drive. ARE YOU CURRENTLY BEINGd TREATEDoctor. Be BYsure ANY to signOTHER Sect DOCTORion 2 in ORthe SPECIALIST presenc maye o be fFOR you currently rANY doct REASON?or taking,. etc. to the consultation.YES NO ...... their ability toIMPORTANT drive. 1. INFORMATION Make an appoin TOtme APPLICANTS!nt with yourour regOnlyular in tr exceptionale4.atiTangke d octorspec tacases focles,r a lonwouldhearig ng a aid persons, the nwhoames hasof any medications you ...... • SIGNATUREThe licence classes that include these vehicles 1. (dExplain45ococtor.YESmitor. nu B thete) e NOs ureconsulreason to tatisign foron. theSect T consultation.heion cos 2 tin of t heth isp rconesensucltatie ofon you isr y docourt or. If yes, please note your recommendations in...... the space below. ARE YOU CURRENTLY BEING TREATED1. BY ANYHave• SIGNATURE IsOTHER aged you 70DOCTOR consultedyears or OR mor SPECIALIST eany 4. (Ta45 medicalkemi sFORnupete)cta ANY cles,consul practitioner REASON?hetatiaringon. aid Thes, the within cos nt amof thies the sof consul any last metati 12dionc atimonths isons you your thatIn DATEsigning the this formmedical...... /...... /...... /...... /...... you consent practitioner to your doctor releasing completing this form does that...... the Driving Assessor should be made aware of (eg. limb mobility, concentration span, etc). • The licence classes that include these• vehicleReturnepilepsys to GPO or diabetes Box 1533, controlled Adelaide by oral 5001 medication or any orService insulin SAbe consideredCustomer rmayespo bens ibil cufor Servicerrity aently .licenceta Centreki ng,to driveetc. to a theavyhe con suvehicle.ltation . If you Should a licence be issued subject to conditions?...... Yes No • SIGNATUREIs aged 70 years or more In DATEsigning this form...... /...... /...... you consent to4.2. your TaComplete doctorke spe releasingcta sectionscles, he ari1 toandng the aid Registrar 2 s,of thethis of Motorn formam Vehicles,es beforeof any any medical handingmedi informationcatio it nsto yothatyouru In my opinion the person who is the subject...... of this report: • areThe MR; licence HR; clas HCses andthat MCinclud rmayes. poe betnshese ibilcu rrityvehicleently. tas kitong, the eRegistrartc. to ofthe Motor con Vehicles,sultati2. any onEnot medicalxp. lresponsibleai ninformation to you rdrthat dforoctoroc thetormay tcosta ecthe rea yourof sonthe ability foconsultation. tortr drivethe safely.consultation...... are MR; HR; HC and MC. not• Has know a medicalhave about? conditioneither Please of these or providedisability conditions the which name it maymay of beaffect medical preferable practitioner to have maydoctor. oryour treatingbe treating cuBerr sureentlyen tlyspecialist to specialist ta signking, Section et c.physician to 2the in ctheon conduct supresenceltation. of your doctor. If yes, pleaseDo...... you providerecommend details conditions below: be placed on ...... the...... applicants driver’s licence? ______• Has a medical condition or disability• whichEnquiries: may affect 13 10 84 2. Explain to yourdr doctoroctormay ta ecthe rea yourson ability fo tortr drivethe safely.cons3. Co ultatimponlete. Sections 1 and 2 of this form before h anding it to your This patient...... has been treated at this clinic for...... years months. What toare MR;do withHR; HC the and completed MC. certificate 3. Take spectacles, hearing aids, the names of any medications you ...... 2. Please their abilityIM listPO all toIMPORTANTRT drive.theAN Tmedications IN3. FOINFORMATION Co RMmpleATte thatIOtheSecN tiexamination ons TO TOyou APPLICANTS!1 A andtakePPLIC 2 of in(prescribed ANthi orders OnlyTS!form to Only in befoavoid exceptional orrined ococtor. twohaexceptionalotherwise).tor.ndi consultations. ngB e casesit s ureto casesyo twouldo ur Attachsign would Saect personlist iona personif 2necessary whoin t hewho has pr esenhas ac ecardiac of you r doctor. If...... yes, please note your recommendations in...... the space below. IMPORTANT INFORMATION TOSIGNATURE APPLICANTS! Only in exceptional cases would a person who has DATE ...... /...... /...... their ability to drive. may be currently taking, etc. to the consultation. Meets the...... relevant medical standard No Yes SIGNATURE epilepsycondition, or diabetesIMPORTANT epilepsy controlled or diabetesINFORMATIONdococtor.tor. by Bcontrolled eoral sure medication TOto signAPPLICANTS!by DATEoral Sect ormedicationion insulin 2...... /...... /...... inOnly t hebe in or prconsidered exceptional esenc4.insulin Taeke o befs peyou forconsideredc tacasesr acles, do licencect wouldheorari. for ngto a adriveaid person licences, the a heavy nwhotoam drivees hasvehicle. of aany heavy medi If you vehicle.cations you Should a...... licence be issued subject to conditions?...... Yes No SECTION 1: - YOUR DETAILS. Please write clearly using BLOCK LETTERS ...... epilepsy or diabetes controlled by oral medication• The licence or insulin classes bethat considered includ4. Takee t shesepe forcta vehicle acles, licence hes ari ngto driveaids, the a heavy names vehicle. of any me If diyoucations you If no, please...... provide details below: ...... • The licence classes that include these• vehicleReturnepilepsys If youto GPO have orhave diabetes anyBox either of 1533, these controlled of these conditionsAdelaide conditions by oral it5001 maymedication it may orbe preferableany be preferableorService insulin to have SAbe to consideredCustomeryourhave may treatingyour be treating cufor Service rrspecialist aentlyen licencetly specialist ta Centreki physician ng,to driveet c.physician to a conduct theavyhe con conduct suvehicle. theltati examinationon . If you in If yes, please provide details below: ...... IMPORTANT NOTES FOR THE MEDICAL PRACTITIONER In my opinion...... the person who is the subject...... of this report: have either of these conditionsSECTION it aremay MR; be1: preferableHR; YOUR HC and to haveMC DETAILSmay. your be treatingcurrentlyently specialist ta(toking, be et c.physician completed to the con conductsultati onnotin. responsibleBLOCK forletters the cost priorof the consultation. to seeing your doctor) ...... are MR; HR; HC and MC. 2. Please list have all theeither medications of these conditions thatthe examination youit may takeorder be preferable in(prescribedto orderavoid totwo to avoid have consultations. or twoyourotherwise). consultations. treating specialist Attach list physician if necessary conduct Requires a practical driving test Please...... answer the following questions Yes / No No Yes •the Enquiries: examinationSeSectioncSURNAMEtion 80 80 13 o f ofin t10he theorder Motor84 Motor to Vavoidehic Vehiclesles two Act consultations. 1Act959 1959 requires requires certain certain applica applicantsnts for a driver for ’sa licendriver’sce t olicence provide to medi providecal evid medicalence o fevidence the ir of t theirness ...... IMPORTANT INFORMATIONthe examination TO APPLICANTS! in order Only to in avoid exceptional two consultations. cases would a person who has ...... SECTIONto drive.IM 1:PO - YOURRTAN DETAILS.T INFORM PleaseATIO writeN TO clearly A PPLIC usingAN TS!BLOCK Only LETTERS in exceptional cases would a person who has a cardiac ...... In...... accordance with the National Transport Commission standards “Assessing Fitness to Drive”- SECTION 1: - YOURIMPORTANT DETAILS. INFORMATION PleaseSurname write TO clearlyAPPLICANTS! using Only BLOCK in exceptional LETTERS cases would a person who has Meets the relevant medical standard ...... YesNo Yes No IMPORTANTepilepsycondition, or diabetes epilepsy NOTES controlled or diabetes FOR by controlled THEoral medication MEDICAL by oral ormedication insulin PRACTITIONER be or considered insulin be forconsidered a licence for to adrive licence a heavy to drive vehicle. a heavy If you vehicle...... SECTIONIMPORTANTGIVEN NAMES 1: - YOUR NOTES DETAILS. FOR Please THE write MEDICAL clearly using PRACTITIONER BLOCK LETTERS ...... epilepsy or diabetes controlled by oral medicationYou are req orues insulinted to cbeomp consideredlete the Me fordi cala licence and Ey toesigh drivet Cer a tiheavy c ate vehicle.overleaf afIf teryou referring to the standards contained in the National If no, please...... provide details below: Do you cnsider the applicant medically and psychologically fit to drive a heavy commercial vehicle? IMPORTANT NOTES FOR THE MEDICALIf you havehave anyPRACTITIONER either of these of these conditions conditions it may it maybe preferable be preferable to have to yourhave treatingyour treating specialist specialist physician physician conduct conduct the examination in Do you recommend conditions be placed on the licence? No Yes Given3. SeTransHave namescSURNAMEtionpor you80t Commission of tbeenhe Motor the pu V ehicdriverbliclaestion A ofct ” 1 a959 vehicle requires involved certain app inlica ants ”crash w forhi cha driver inis avai the’sla licen blelast fromce 5 t oyears? Austproviroade dsmedi onYesDate cal(02) e vid9 26ofence4 7088birth ofNo thore at ir tness Please...... answer the following questions Yes / No have either of these conditionsSECTIONSection it may be801: preferable of theYOUR Motor to have VehiclesDETAILS your treatingActAssessin 1959 specialistg(to requires Fitness be physician tcertainocompleted Drive applicants conduct in for BLOCK a driver’s letterslicence to prior provide to medical seeing evidence your of theirdoctor) PleasePlease answer answer the followingthe following questions questions Yes / No Yes /D NoEC...... LARATION SecSURNAMEtion 80 of the Motor Vehicles Act 1959 reqNationaluires certa Transportin applica ntsCommission for a driver’s publication licenthece examination to p rovi“Assessingorderde me intodi orderavoidcal Fitness evi totwod enavoid toceconsultations. Drive”o ftwo the consultations. whichir tness is available from Austroads on (02) 9264 7088 ...... If ‘No’, do you consider the applicant medically and psychologically fit to drive a light vehicle? the examinationtowww HOMESURNAMEdrive.aus. ADDRESStroad ins. ordercom.au to. avoid two consultations...... PleaseIn accordance answer thewith following the National questions Transport Yes / Commission No standards “Assessing Fitness to Drive”- to drive. IMPORTANTorIf Yes,at www.austroads.com.au. please provide NOTES details FOR THE MEDICAL PRACTITIONER InIn accordance accordance with with the National the National Transport Transport Commission CommissionDo standards...... N youAME consider OF “Assessing MEDIC standardsthatAL it Fitness is prudent “Assessing to Drive”- or necessary Fitness for the to applicantDrive”- to undergo a practical driving assessment? PROVIDER HomeSECTIONYou addressGIVEN are reqNAMES 1:u es- YOURted to c DETAILS.omplete the Please Medical write and clearlyEyesigh tusing Certi c BLOCKate over LETTERSleaf after referring to the standards contained in the National Please provide...... further details on any of theInDo...... accordance you above cnsider with the questions theapplicant National medically Transport below: and Commissionpsychologically standards fit to drive “Assessing a heavy Fitness commercial to Drive”- vehicle? SECTIONIMPORTANTGIVEN NAMES 1: - YOUR NOTES DETAILS. FOR Please THESurname write UnderMEDICAL clearly sect ionusing 14 PRACTITIONER8 ofBLOCK the Motor LETTERS Vehicles Act you have a legal obligation to inform the RegistrarDAYTIME of Motor Vehicles if you Do...... you cnsider the applicant medically and psychologicallyPRACTITIO fit to driveN aER heavy (Ple ascommerciale Print) vehicle? ______NUMBER You are requested to complete the Me3.dical aTransSehaUnderHavendcSUBURB/TOWNGIVENv tioneEy reasonablepesighor you 80NAMESsectiont Commission otf Cer beentheti c148Motor cause athete of puto overV the ehicdriverbelieveblicle Motoralafestion af A tterofctha ” 1 trefAssessinVehicles a9the59 vehicleerrin areqppligu gto irescAct Fitan tinvolvedhe certness youis st tasufferinan int haveodards appDrive in glia cac fromontlegalantsPOSTCODE ”crash aw forinea hiobligation p chdahy driverin inissi t cavai hetheal ’s orNla licen blemenlasttoat informfromceion tal5 t oalillnessyears? Austp rovi thePHONEroa,de disabi Registrar ds medi No.onYeslit cal(0y 2)or e vid9 ofdef26 enceMotor4icienc 7088 ofyNo thor Vehiclese at ir tif nessyou DDoEC...... youLA cnsiderRATIO the Napplicant medically and psychologically fit to drive a heavy commercial vehicle? SeTransctionpor 80t Commission of the Motor pu Vehicbliclaestion Act ” 1Assessin9Suburb/Town59 reqNationalugires Fit cernessta Transport into appDrivelica ntsCommission” w forhi cha driver is avai’s publicationla licenble fromce to Austp rovi“Assessingroade dsme ondi cal(0 Fitness2) evi 92d64en Postcode to7ce0 88Drive”of torhe at whichir tness is available Daytime from Austroads phone on no (02) 9264 7088 FurtherDECL...... ARA commentsTION on medical condition(s)PleaseNOTEIf ‘No’, answer: doA practical affectingyou the consider following driving the safeassessment questionsapplicant driving medicallycannotYes / No beare and undertaken psychologicallyattached. if the applicant fit to drive is considereda light ______vehicle? to be medically or psychologically unfit to drive. GivenwwwtotIfha names HOMESURNAMEdYes,trive would.aus. ADDRESS pleasetro affecads.ct om hisprovide .auor .her abili detailsty to drive safely. Date of birth If ‘No’, do you consider the applicant medically and psychologically fit to drive a light vehicle? towww HOMESURNAMEdrive.aus. ADDRESStroads.com.au. or at www.austroads.com.au. PleasePleaseDo you answer answer consider the followingthe thatfollowing itquestions is prudent questions Yes / orNo necessaryYes / NoIfDo ‘No’,recommendingN you AMEfor doconsider theOF you MEDIC applicant consider that a practicalAL it isthe prudentto applicantdriving undergo or assessment, necessary medically a practical for andplease the psychologically applicantdrivingnote in the toassessment? spaceundergo fit to below drive a practical anya light particular______vehicle?driving factors assessment? in relation to this patientPROVIDE that theR Driving Assessor should be made HOMEPOSTAL ADDRESS ADDRESS (If di erent from above) In ADaccordanceDRESS with the National Transport Commission standards “Assessing Fitness to Drive”- Postal4. UnderYouIfIs yo addressdriving ua rec seonsi reqctiondu eresaif 14tth significanteddifferent8at ofto the thecomp app Motorleteli cafrom partnt theV isehi Meunofabovecles tdi your cal tActo d a rive nd youoccupation Ey y haouesighve are at legalreqCeru tiores cobligatt aedvoluntaryte tooverion immele toaf informdi af atworkterely ref trethee (e.g.rrinu Rerng gt heto iscouriert trarcheomDAYTIME ofstp anMotorle tedadriverdrds cer Vehicles ctoni orcatetained community ifto y inou t hePO Na Box bus 1,tional driver)? Yes No RequiresDoInNA youaaccordanceME practical consider OF MEDICA that with itdrivingL is the prudent National testor necessary Transport for the applicantCommissionawarePRACTITIO of to(eg. undergo limbN standardsER mobility, ( Plea practicalase Prin “Assessingconcentrationt) driving assessment? Fitness span, etc). to Drive”-No PROVIDEYesR NUMBER YouUnder are se reqctionues t14ed8 ofto thecomp Motorlete theVehi MeclesHomedical Act a ndyou address Ey haesighve at legalCerti cobligatate overionle toaf inform after ref theerrin Regg toist trarheDAYTIME ofst anMotordards V cehiontcalesine ifd y inou t he N ational In accordance with the National Transport CommissionDo standards you consider “Assessing that it Fitness is prudent to Drive”- or necessary for the applicant to undergo a practical driving assessment? haTransWalUndervSUBURB/TOWNGIVENeke reasonableprvor illsectionNAMESt e,Commission 5081 c148ause. of topu the believeblic Motoration tha ” tVehiclesAssessin the applig cAct Fitantness youis sufferin thaveo Drive ga fromlegalPOSTCODE” w a hiobligation pchhy siis cavaial orla blemento informfromtal illness Aust theDAYTIMEPHONEroa, disabi Registrards No.onlit (0y 2)or 9 ofdef26 Motor4icienc 7088y or Vehicles at if you NOTE:PRACTITIONER A practical (Please driving Print) assessment cannotDDoNOTEEC youbeLA : undertakencnsiderARATIO practical the Ndrivingapplicant if the assessment medicallyapplicant cannot and is psychologically considered be undertaken tofit if tobethe drive medicallyNUMapplicant a BERheavy is commercialconsideredor psychologically to vehicle? be medically or psychologically unfit to drive.TranshaSUBURB/TOWNGIVENve reasonablepor NAMESt Commission cause puto believeblication tha ” tAssessin the appliAREgc Fitan YOUtness is sufferin CURRENTLY to Driveg fromPOSTCODE” BEING w ahi pchhy TREATEDissi cavaial orla blemen BY from tANYal illness Aust OTHERPHONEroa, disabili dsDOCTOR No.on ty(0 2)or OR 9 defi2 64SPECIALISTc 7ien088cy or at FOR ANY REASON? YES NOGPO Box FurtherDDoECL youARA cnsidercommentsTIO the Napplicant on medically medical and psychologically condition(s) fit to driveaffecting a heavy commercial safe driving vehicle? are attached. ______DAYTIME wwwtIfha SUBURB/TOWNtyou would.aus answeredtro affecads.ct omhis .auor "Yes", .her abili approximatelyty to drive safely. how many hoursPOSTCODE per day do you drive?PHONE No. Hours: NOTE: A practical driving assessment cannot be undertakenSUBURB/TOW if the applicantN is considered to be medically or psychologically unfit to drive. POSTCODE PHONE No. wwwthat would.austro affecads.ct omhis .auor .her ability to driveSuburb/TownEmail safelIf1533, youaddressy. c onsiAdelaided (ifer th available)at SA the 5001. applicant is t to drive you or the applicant sho Postcodeuld return t he completedIn signing cer ti Daytime cthisa formte in you person consent phone to to your an doctor no releasing y Registration NOTEIf ‘No’,recommendingNADAMEDRES: doA OF practical youS MEDIC consider a drivingpracticalAL the assessment applicantdriving assessment, medicallycannot be and pleaseundertaken psychologically note in if thethe spaceapplicant fit to below drive is consideredanya light particular______vehicle? to befactors medically in relation or psychologically to this patientPROVIDE unfit that to theR drive. Driving Assessor should be made UnderIfan yoHOMEPOSTALd uLi c onsiseensin ADDRESSct ADDRESSiondger Cen 14th8at (Iftof ret di erenthe theor app Service Motorli fromcant SAV above) isehi Centreuncles t t Acto or d rive mayouil y haitou tveo a re a POreqlegal Buoxes obligatt 1,ed Wa toion lkeimmerv toill informdie, at50e81.ly tret heu RernI gntheis eithert rarctoom the of capRegistrar Motorlese,te dit of iscer MotorVehicles reti c ommendedVehicles,cate ifto any y ou medical PO tha informationBoxt you 1, kee thatp a If ‘No’,recommendingNAADMEDRE do OFSS you MEDICA consider a practicalL the applicantdriving assessment, medically andplease psychologically note...... in the space fit to below drive anya light particular vehicle? factors in relation to this patientPROVIDE that theR Driving Assessor should be made If yoHOMEPOSTALu consi ADDRESS ADDRESSder that (If t di erenthe appli fromcant above) is un t4. to driveIs driving you are reqa significantuested to imme partdiat eofly retyoururn toccupationhe completed ceror tvoluntaryi cate to POwork Box 1,(e.g. couriermay a ect yourdriver ability to or drive community safely. bus driver)? Yes No Do you consider that it is prudent or necessaryDoIfaware recommendingPRACTITIO you for of consider the(eg. limbapplicantN ERthat a mobility, practical(Ple it asise prudentPrinto driving concentrationundergot) or assessment, necessary a practicalspan, for please etc). the applicantdrivingnote in the toassessment? spaceundergo below a practical any particular______driving factors assessment? in relation to this patientNUMBE thatR the UnderDriving seAssessorction should 148 of be the made Motor Vehicles ActhaWalc youopvPOSTALekey hareasonablefrvorveill y e,ADDRESSou a 50legalr o81wn c obligat ause(If re. di erentcor tods.ion believe from to inform above) that t thehe a Reppligiscantrart isof sufferin Motor gV ehifromcles a pifhy yousic al or mental illness, disability or deficiency awareIfPRACTITIONER recommending of (eg. limb mobility, (Please a practical Print concentration) driving span, assessment, etc). please note in the space below any particular factorsNUM inBER relation to this patient DAYTIME YES NO Do you consider that it is prudent or necessary for the applicant to undergo a practical driving assessment? DAYTIME haWalveke reasonablerville, 5081 cause. to believe that tPostalIhe declare applithaARE addressctan would YOUthatt is sufferin CURRENTLY affec to if thedifferentt ghis from orbest BEINGher a p ofabili hyfrom TREATED simyctyal t oorknowledgeabove drive men BY tsafelANYal illness y.OTHER DAYTIMEthe, disabili DOCTOR abovety or OR informationdefi SPECIALISTciency FOR is ANYtrue REASON? and correct and that I have madeGPO Box the medical Requires a practical driving test aware...... SIGNATUR of (eg. limbE mobility, concentration span, etc). YesNo Yes No DATE ...... /...... /...... ARE YOU CURRENTLY BEING. TREATED BY ANYIfApServiceIf you SIGNATURESUBURB/TOWN plyouOTHERic canonsi SAansweredts DOCTORwd Centreerho th hoatld t ORheor a"Yes", l appicencemailSPECIALISTli cait other ntapproximatelyto is GPO tFOR than to ANY dBox arive b asicREASON? y1533,ou “ca orhowr” t Adelaidehelicence appmanyli acare ntSA hoursreqPOSTCODE sho 5001.uireuld per reto InYEStu u dayrnndeither ter he go do NOc case, oma youpplra eteditcti drive?iscalIn PHONEDATE signingrecommendedc derrivinti c this No.gHours:a form teassessment...... /...... /...... in you person consent that to toa youyourt agean doctor keep 85 releasing y Rea copy gandistra every fortion Medicalthat Practitioner’s the Driving Assessor signature should be made awareSUBURB/TOW of (eg. limbN mobility, concentration span, etc). DAYTIME POSTCODDateE PHONE No. thatSUBURB/TOWN would affect his or her ability to drive1. safel1533,HaveAREy. YOU Adelaideyou CURRENTLY consulted SA POSTCODE5001. BEING any TREATED medical BY practitionerANY OTHERPHONE DOCTOR No. within OR theSPECIALIST last 12 FOR months ANY REASON? that the medical practitionerYES NO completing this form does NOTE:SUBURB A/TOW practicalN driving assessment cannotNOTEAD beDRES : undertakenA practicalS driving if the assessmentP applicantOSTCOD cannotE is considered be undertaken to if bethe medicallyPapplicantHONE No is .consideredor psychologically to be medically or psychologically unfit to drive.If you consider that the applicant is t topractitioner driveIfanyearyour yoydou uLi therea cownoronsiensin the completing dftrecords. appger Cen .th Howliatcatre tntheever or sho app Service, iulthisf liyoudca rent tuformcSA onsiderisrn Centreun the t aware c titoom or prd riveplmaudete enofil y itInoudt signingortanycero a nereti POthis creqmedicalcateess form Buaroxes in youy t1, edyperson consento Wau to conditionmlke imme ayto trv youro recommen illa ndie,doctor at50e 81.releasingly ythat Rret egisdu arn pItr I racticanhavetathe eitherion ctoom the l andd ca pRegistrarrivinlese,te drugsgitd of aiscer ssessmentMotor retci ommended Vehicles,cateor medication to anya t medicalanPOy t haag informationBoxte you 1, that kee thatp Ia use. NOTE: A practical driving assessment cannot be undertaken...... if the applicant is considered to be medically or psychologically unfit to drive. Email address (if available)Please provide the nameto of the medical Registrar of Motor practitioner Vehicles, any medical or treating information specialist that mayIn signing a ect this your form ability you to consent drive safely. to your doctor releasing ADDRESS If recommending...... a practical driving assessment, please note in the space below any particular factors in relation to this patient that the IfanDriving yod uLi c onsiAssessorensindger shouldCen thatt ret behe or made app Service licant SA is Centreun tI consent to or dcWalirres rivenotmaopkeyil pecy ifouknow torrvto totiveill ay e,reoumy 50POoreqr foabout? 81t medicalwnBheuoxes claret .1,ed css orWa to ofds. lkeimme practitionerlicrvenillcdie,e athe50e81.ldly bret y ut heand/orrnI ntahep eitherpl ciomca myn capt.le se, treatingte dit iscer reti commencat specialiste to dedPO th atBreleasingox you 1, keep a toto the the Registrar Department of Motor Vehicles, any medicalof Planning, information that Transport and FOLD POSTAL ADDRESS (If di erent from above) IfDo recommending...... you recommend a practical conditions driving assessment, be placed please on note the in applicantsthe space below driver’s any particular licence? factors in relation to this patient that the Driving ______Assessor should be made Walcopkey frvorill ye,ou 50r o81wn re. cords. may a ect your ability to drive safely. awareSIGNATUR...... of (eg. limbE mobility, concentration span, etc). DATDAYETIME...... /...... /...... POSTAL ADDRESS (If di erent from. above)IInfrastructure declareApplicants that towhoany the holdmedical best a licence of information my other knowledge than arelating basic the “car” above to licence my informationability are required to drive to is undergo true safely. and amay practical a ectcorrect your ability driving and to drive that assessmentsafely. I have at made age 85 theand medical If yes, please note your recommendations in ...... the space below. DAYTIME ...... /...... /...... ApIfService youSIGNATUREplic canonsi SAts wd Centreerho th hoatld t heor a l icenceappmailli cait other ntto is GPO t than to dBox arive basic y1533,ou “ca orr” t Adelaidehelicence appli acare ntSA req sho 5001.uireuld reto Intu u ndrneither terhego ccase, oma prapl itcetedti iscal DATErecommended c derrivinti cga teassessment...... /...... /...... in person that atoyout agean keep 85 y Rea copy gandistra every fortion MedicalawareIf ...... SIG Practitioner’srecommending NofATUR (eg. limbE mobility, a signaturepractical concentration driving span, assessment, etc). SUBURB/TOW please noteN in the space below any particular factorsDAT Ein relation...... /...... /...... P OSTCODtoDate this patientE . PHONE No. SIGNATURE everyARE YOU year CURRENTLY thereafter. BEINGHowever, TREATED if you BY consider ANY OTHER it prudent DOCTOR or OR necessary SPECIALIST you FOR may ANY recommend REASON? a practical driving YESassessment NO at any Should a licence be issued subject to conditions? POSTCODE No Yes IfAp yopluic canonsits wderho th hoatld the a l appicenliceca otnther is t than toIpractitioner have d arive bayearanyour siy dmadeouc Li“thereaca ownorcensinr” the l icencompleting theftrecords. appger ceCen. Howmedicalli acaretrent everreq or sho uService, irediulthisf practitioneryoud reto tuformcSA undonsiderrn Centre terhe goaware c it oma orpr pcompleting plraudmaetect enofilic itdtal DATEortanycer odrivin neti PO cmedicalcateessg thisBaaroxssessmen...... /...... /...... iny 1, ypersonformo Wau conditionmlkeayt tatawarervo recommen illaganYESe,e 50 8 5 81. yof that R egisNOdany an a pdItr Iracticanhave atevermedical eitheriony l andd carivinse, condition drugs git aisssessment recommended or medicationthat at an Iy t haveaghaet you andthat keep drugs Ia use. or medication Medical SUBURPractitioner’sB/TOWN name ...... PHONE No. ARE YOU CURRENTLY BEING TREATED1. BY ANYyearageHaveSIGNATURE OTHER irrespectivetherea you DOCTORft erconsulted. How of ORtheever SPECIALIST class, i fany you of cmedical licenceonsider FOR ANY heldit prpractitioner udREASON? byen thet or applicant.necess withinary you the may lastrecommen 12 monthsd a practica thatIn DATEsigningl d rivinthe thisg formmedical a...... /...... /...... ssessment you consent practitioner to ayourt an doctory ag releasinge completing this form does that the Driving Assessor should be made aware...... of (eg. limb mobility, concentration span, etc). anyeard Li therecensinaftger Cen. Howtreever or Service, if you cSAonsider CentrethatI consent it orpr cirres Imaud opuse.entilypec if torto ortIotive y consentnecessaryoumy POor fo t medicalwnBheox clare 1,ytocouss Waor of ds.mymlke practitionerliaycrv en medicalreillcce,eommen he5081.ld b practitioneryd t aheand/or prI naacp eitherplticaInica signinglmy nd cat.rivin se, and/orthistreating g itform aisssessmen reyouc consentommenmy specialist treatingtot atyourd anyed doctor th age at releasingreleasing specialist you keep a toto releasing the the Registrar Department of Motor to Vehicles, the anyDepartment medicalof Planning, information that for Transport Infrastructure and and FOLD If yes, please provide details below: Provider Number FOLD ...... cirresopypec fortive you or fo twnhe clarecssords of l.icence held by the applicant. to the Registrar of Motor Vehicles, any medical information that may a ect your ability to drive safely...... FOLD Transport2.InfrastructureSignatureApplicantsnotPlease know any list whomedicalany about?all theholdmedical medications aPleaseinformation licence information provide other thatthe thanrelating name you arelating basic oftake to “car”medical my (prescribedto licence ability my practitioner ability are to required ordrive to orotherwise). treatingdrive safely.to undergo safely. specialist Attach a practical list if necessarydriving assessment Date at age 85 and ...... SIGNATURE DATE ...... /...... /...... Applicants who hold a licence other than a basic “camayr” a ect licence your ability are to req driveu iresafely.d to undergo a practical driving assessment at age 85 and every DoSIG youNATUR recommendE conditions be placed on the...... applicants driver’s licence? DATE ...... /...... /...... ______. every year thereafter. However, if you consider it prudent or necessary you may recommend a practical driving assessment at any Further...... comments on medical condition(s) affecting safe driving are attached. Applicants who hold a licence other than a bayearsic “thereacar” licenfterce. How are everrequ, iredif you to c undonsiderergo it a pr praudctenicalt or drivin necessg aarssessmeny you mtay at recommen age 85d an a dp racticaevery l driving assessment at any age MedicalIf Practitioner’syes, please note your name recommendations in ...... the space below. Pleaseage SIGNATUREnote: irrespective Your ofmedical the class practitioner of licence held hasby the a legalapplicant. obligation to inform the RegistrarDATE ...... /...... /...... if they believe that a person they have Practice ...... Address ...... yearSIGNATURE thereafter. However, if you consider it prirresudentpec ortive necessary of the cla youss of m liaycen receommen held byd tahe pr aacpplticaicaDATEl dnt.rivin g a...... /...... /...... ssessment at any age Should a licence be issued subject to conditions?...... ProviderYesNo NumberYes No FOLD IMPORTANT NOTES FOR THE MEDICAL PRACTITIONER ...... irrespective of the class of licence held examinedby the applica isnt. suffering from a medical condition such that they endanger the public if they drove. FOLD Signature Date IIf certify yes, please that I providepersonally details examined below: the above...... named patient in accordance with the “Assessing Fitness to Drive” guidelines. If the Section 80 of the Motor Vehicles Act 1959 requires certain applicants for a driver’s licence to provide medical evidence of the ir tness ...... Section 80 of the Motor Vehicles Act 1959 requires certain applicants for a driver’s licence to provide medical evidence of their ...... 2. toPlease drive. list all the medications that you take (prescribed or otherwise). Attach list if necessary applicant holds a driver accreditation, I have...... considered that they are medically and psychologically fit to drive a public passenger PleaseA person note: must Your not, medical in providing practitioner information, has a legal obligation make a statement to inform the that Registrar is false if or they misleading. believe that Penalties a person theyapply. have Practice ...... Address ...... IMPORTANT NOTES FOR THE MEDICAL PRACTITIONER vehicleTelephone and...... Numberhandle passengers. Facsimile Number E-mail Address IMPORTANT NOTES FOR THEexamined YouMEDICAL are is req sufferinguest edPRACTITIONER to c ompfromlete athe medical Medical aconditionnd Eyesight Cersuchti c thatate over theyleaf afendangerter referring theto the publicstanda rdsif theycontained drove. in the National ...... Please3. IMPORTANTTransSeHave cnote:tionpor you80t Commission Yourof beenthe Motormedical NOTES the pu V ehicdriverblic practitionerales tionFORA ofct” 1 Assessin a9THE59 vehicle req MEDICALhasugires Fit involveda cerness legalta into appDrive obligationPRACTITIONER inlica ants ”crash w forhicha driverintois avai theinform’slablelicen lastfromce 5the t oyears? Austp roviRegistrarroade dsmedionYescal (0if2) ethey vid926ence4 7088believe ofNo thoreat thatir t aness person they have ...... DEC...... LARATION Section 80 of the Motor Vehicles Act 1959 reqNationaluires certa Transportin applica ntsCommission for a driver’s publicationlicence to p rovi“Assessingde medical Fitness eviden toce Drive” of the whichir tness is available from Austroads on (02) 9264 7088 ...... examinedwwwSetoSectionIf cdYes,tionrive.a us is.80 80pleaset rosuffering o adfof the s.thec Motor omprovide Motor.au from .Vehic Vehicles detailsl esa Amedicalct 1Act959 1959 req conditionuires requires certain certainsuch applica that applicantsnts for they a driver formay ’sa licendriver’s endangerce t olicence provi dethe to medi providepubliccal evid medicalifence they o fevidence drove.the ir of t theirness ...... to drive. A personor at www.austroads.com.au. must not, in providing information, make a statement that is false or misleading. Penalties apply. Telephone...... Number Facsimile NumberNAME OF MEDIC AL E-mail Address PROVIDER UnderYouto drive are se. reqctionues 14ted8 of to thecomp Motorlete theVehi Meclesdical Act and youEy haesighve at legalCerti c obligatate overionle toafinform after ref theerrin Regg toist trarheofst anMotordards Vehicles contained if y inou the National Medical Practitioner’s signature Date You are requested to complete the Medical aIMPORTANTnd Eyesight Certi c NOTESate overleaf FOR after ref THEerrin gMEDICAL to the standards PRACTITIONER contained in the N ational PRACTITIO...... NER (Please Print) NUMBER haTransYouUnderve a reasonablepreor reqsectiont Commissionuested c148ause to cofomp topu thebelieveblleteic Motoration the tha ”Me tVehiclesAssessin tdihecal ap aplindg cAct FitanEyesightness youis sufferin thave oCerDriveti g ca fromalegalte” overw a hiobligation pchhyleafsiis caf avaialter orlable ref mentoe rrininformfromtalg illnesstoAust t hetheroa, st disabi Registrarandsdaonlrdsit(0y 2)coron 9ofdef26tained Motor4icienc 7088 iny ortVehiclesheat Na tionalif you ...... DECLARATION IMPORTANTTransport Commission NOTES publica tionFOR” Assessin THE MEDICALg Fitness to Drive PRACTITIONER” which is available from Austroads on (02) 9264 7088 or at FurtherDECLARA commentsTION on medical condition(s) affecting safe driving are attached. SECTION3. TranswwwSetHavehacttionwould.apor us you80 t2:t roCommission o affecadf beentheIMPORTANTs.ct Motor omhis the.auor pu. herV ehicdriverbl abiliicalestionty A ofctt ”o 1 driveAssessina9 59 NOTESvehicle reqsafelugiresy. Fit involved cerness taFOR into appDrive inli caTHE ants ”crash w for hi chaMEDICAL driver inis avaithe’slablela licen blelast fromce 5 t oyears? Aust pPRACTITIONERroviroade ds medi onYes cal(02) e vid926ence4 7088 ofNo thore at ir tness SECTION 4: EYESIGHT CERTIFICATE (Must be completed in all cases) DEC...... LARATION wwwSection.aus 80tro oadf thes.c Motor om.au .Vehicles Act 1959 reqNationaluires certa Transportin applica ntsCommission for a driver’s publication licence to p rovi“Assessingde medical Fitness eviden toce Drive”o f the whichir tness is available from Austroads on (02) 9264 7088 ...... ADNAMEDRES OFS MEDICAL PROVIDER UnderwwwIftoIfyo dYes,riveu.a cusonsi se. pleasecttroiondader s.14 thc8atom provideof the.authe app. Motorli cadetailsnt V isehi uncles t t Acto drive you y haouve are a reqlegalues obligatted toion imme to informdiately tretheu Rern gtheist rarcomofp Motorleted cer Vehiclesti cate ifto you PO Box 1, Medical NAPractitioner’sME OF MEDICAL name PRACTITIONER (Please Print) PROVIDER NUMBER Underto drive se. ction 148 of the Motor Vehicles4. ActorIs you drivingat ha www.austroads.com.au.ve a legala significant obligation t opartinform of tyourhe Re goccupationistrar of Motor or Vehi voluntarycles if you work (e.g. courier driver or community bus driver)? Yes No NAME OF MEDICAL PROVIDER TheThe Registrar RegistrarhaUnderYouWalveke a reasonablererv se ill req ctofe,ion u50of esMotor81 14t edMotor c8ause of to. the cVehiclesomp to VehiclesMotorbelievelete theV tehirequiresha Me requirestc lestdihecal Act ap apli ndyou certainc certainanEy haesight isve sufferin a applicantst legalCer applicantsti g cobligat fromate over ionafor p hyforle t oafasi inform cafdriver’saalter driver’s or ref mentheerrin Re licence,talg glicence, illnesstoist trarhe , ofst ordisabi anMotor or licenceda lrdslicenceit y Vehicles corondef holders,tained iholders,cienc if y inouy t he to Nato provide providetional evidence evidence of of their their fitness 11. If the patient has one or more of the following eye or vision conditions, please tick condition/s. PRACTITIONER (Please Print) NUMBER DAYTIME haYouve a reasonablere requested cause to comp to believelete the tha Met tdihecal ap aplindc anEyesight is sufferint Certig cfromate over a phyleafsi cafalter or ref menerrintalg illnessto the, st disabiliandardsty corontdefiaineciend incy the N ational GPO Box PRACTITIONER (Please Print) NUMBER tofitness drive.haTranstIfUnderIfha you vPlease:you tetowould reasonablep c oronsi sectiondrive.answeredt Commissiond affecer th tPlease:c148athisause the or "Yes",of topuapp her the believebl liabiliicca Motora tionntapproximatelyty ist hat ”o t tdriveVehiclesAssessin tothe d arivesafelppli yg couActy. Fit an orthowness youis t hesufferin t haveoappmany Driveli caga fromnt legalhours sho” w a hiulobligation pchd hyper re siistu c avai aldayrn or tlablelahe blemen todo c om informfrom tyoualpl illness eted Aust drive? the croa,er disabi Registrartids c onHours:alteit (0y in 2)orperson 9 ofdef26 Motor4icienc 7088 to any or Vehicles at y Reg ifistra yoution DECSUBURB/TOWLARATIONN POSTCODE PHONE No. tTranshat wouldport Commission affect his or pu herbl abiliicationty t ”o driveAssessinsafel1533,gy. Fit ness Adelaide to Drive SA 5001.” which is availablelable from Austroads on (02) 9264 7088 or at FurtherDECLARA commentsTION on medical condition(s)ADDRES affectingS safe driving are attached. Ifanwwwthayodt uLiwould.a cusonsiensintro daffec adger Cens. thct atomhistre the .auor or app. her Service liabilicantSAty is t Centreoun drive t to or safeldrivemay.il y itou to arePO req Buoxes t1,ed Watolke immervilldie, at50e81.ly returnI nthe either com caplese,te itd iscer retci ommendedcate to PO thaBoxtyou 1, keepa Cataracts Diplopia Glaucoma Macular Degeneration ADDRESS Ifwwwyou.a cusonsitrodaders. thcatom the.au app. licant is un• t•refer trefero drive to to y sectionou the are National req 1ues thatted to Transporthas imme beendiate lyCommission’scompleted return the com by ppublication leyourted cer patient;ti cat e“Assessing to PO Box Fitness 1, to Drive 2016” private standards for light vehicle licence. Medical Practitioner’s practice address ADNAMEDRES OFS MEDICAL PROVIDER cUnderIfWalop yokeyu f corrv onsi seill ycte,ouiond 50rer o81 14wn th8at ofre .the ctheor appds. Motorlicant V isehi uncles t t Acto drive you y haouve are a reqlegalues obligat ted toion imme to informdiately tretheu Re rn gtheist rarcom ofp Motorleted cer Vehiclesti cate ifto y ou PO Box 1, Poor Night Vision Retinitis Pigmentosa Other condition which may impair their ability to drive (please specify) NAME OF MEDICAL PRACTITIONER (Please Print) PROVIDER NDAUMBEYTIMRE WalUnderkerv seillcte,ion 5081 148 of. the Motor Vehi• cles4. Irefer declare TheAct Is youto guidelinesdriving hathethatve Nationala to legala significantthe are obligat best availableTransportion of t opart myinform from ofknowledgeCommi tyourhe AustroadsRe gsoccupationis sion'strar the of Motorpublication atabove www.austroads.com.au or Vehi voluntary informationcles “Assessingif you work is true(e.g.Fitness andcourier to correct Drive driver 201and or6 ”thatcommunity private I have standards madebus driver)? the for medical lightYes vehicle No licence. SIGNATURE DAYTIME DATE ...... /...... /...... haApIfWalService youvpleke icreasonable crvanonsi illSAte,s wd 50Centreerho81 th ho catauseld .t heor a l toicenceappmail believeli cait otherntto ist haGPO t thant tothe dBox aarive pbpliasic y1533,couan“ca ort r”is tAdelaide he licsufferin ence appli acagre fromntSA req sho 5001.u aireul pdhy reto siIntu cual ndrneither or terhe men go ccase,om a tpalrapl illness itcetedti iscal recommended c,der disabirivinti cga lteaitssessmenty in orperson def thaticienc atoyout ageany keep 85 y Rea copyg andistra every fortion Medical PRACTITIONERPractitioner’s (Please signature Print) SUBURB/TOWN NUMBER POSTCODDateE DAPHONEYTIM NoE . Ifhayoveu reasonable consider th catause the toapp believelicant istha tt tot practitionerhe d(your ariveppli ycouan assessmentort is the sufferin completing applicag fromntmust sho a ul this pbedhyresi undertakentuformcalrn or the menaware comtalpl illness ete inofd accordance anycer, disabiliti medicalcatetyin or person defiwith conditioncien t othecy an guidelines); ythat Regis Itr haveation and drugs or medicationGPO that Box I use. Visual Field Defect SUBURB/TOWN POSTCODE PHONE No. yearantIfyourIfha you dyout Liwouldtherea ownconsiensin answered dftrecords.affec ger Cen . th Howt athistre teverhe or or"Yes", app her Service, if youliabilica ntapproximately cSAtyonsider is t Centreo t drive to d itrive or prsafeludma youy.enil it t orhow orto t henePO cappmanyess Bliaroxcay 1,nt yhourso Washou mlkeulayd rv perrecommen reille,tu 50dayrn 81.the do dcom a youpplIracticaneted either drive? l c der carivintise, c Hours:ga itte a isssessment in re personcommended toat any tagha yety Reougistra keepation SUBURB/TOWN POSTCODE PHONE No. anthatd Liwouldcensin affec g Cent histre or or her Service abiliSAty tCentreo driveI(your consent orsafelcirres1533,maop assessmenty.ilypec if torto tAdelaideotive y oumy POor fo t medicalwnBheox must SAclare 1,css Waor5001. ofds. belke practitioner licrv enundertakenillce,e he5081.ld by t heand/or I innap either placcordanceica myn cat. se, treating it is re withcommen specialist theded guidelines); th atreleasing you keepa to the Department of Planning, Transport and Telephone Number Facsimile NumberADDRESS E-mail Address FOLD Ifan yod uLi consiensindger Cen thattre the or app Servicelicant SA is Centreun t to or d rivemail y itou to a re PO req Buoxes t1,ed Wa tolke immervilldie, at50e81.ly ret urnI nthe either com caplese,te itd iscer retci ommendedcate to PO tha Boxtyt you 1, keepap a copy for your own records. • pleaseApplicants complete who hold all ofa licence sections other 3 thanand a5; basic “car” licence are required to undergo a practical driving assessment at age 85 and Note: If the patient has one or more of the above conditions and the eyesight standards are not met (aided) an Optometrist ADDRESS SIGNATURE DATE ...... /...... /...... If you consider that the applica. nt is un• tInfrastructure to dcWalriveopkey y fouorrvill aye,reou 50 reqrany o81wnues medicalret.ed cor tods. imme informationdiately return t herelating comple tetod cermyti abilitycate to toPO drive Box 1, safely. if youApevery areplic anyear familiarts wthereafter.ho ho ldwith a lHowever,icence your other patient's if thanyou considera b asicfull“ camedical itr” prudent licence history,a reor reqnecessaryuire youd to youu onlynd ermaygo need arecommend pra ctotical completedrivin a practicalg assessment the driving parts at age assessmentof 85 section and at every 3any relevant to the patient's or Ophthamologist must complete the Eyesight Certificate. SIGNATURE DATE ...... /...... /...... DAYTIME ApWalplkeicrvanillte,s w 50ho81 hold. a licence other than•I declarepleasea basic “ cathatcompleter” licen toce the are section reqbestuired of 4t o myif und your knowledgeergo patienta practical thehas drivin aboveag vision assessmen information or teye at ag disorder,e 85 is trueand or ever and isy required correct andto wear that glasses I have madeor corrective the medical lenses; PleaseMedical complete Practitioner’s if a specialist name has assessedSIGNATUR any ofE the patient’s conditions in additionDAYTIM Eto the treating medical practitionerDATE ...... /...... /...... medicalyearApIfServiceage youpl irrespective thereaicconditions canonsi SAts wdft Centreerho . th Howho atofld t andtheeverheor a l icenceappmail class, iallf youli cait of othernt toc licenceonsider issections GPO t than to dhelditBox arive prb asic4ud y1533,by ouanden “ cathe tor orr” t 5; Adelaideheapplicant. licneence cappessliar acarey ntSAy reqo shou 5001. umireulayd recommen reto Intu u ndrneither terhego dccase, om aa ppraplractica itcetedti iscal recommended lc dderrivinrivinti cgga te aassessmentssessment in person that atoayoutt agean keepy 85ag ye Rea copy g andistra every fortion Medical Practitioner’s signature SUBURB/TOWN POSTCODDateE PHONE No. yearIf youthere consiaftder .th Howat teverhe app, if yolicaunt consider is t to practitioner ditrive prirresud youentpec or ortive the necessarycompleting oappf thelica cla ntyouss sho ofm ul lithisaycden re rec tuformeommen hern ldthe baware ydc om taheprpl aacpete plofticadica lanycer dnt.rivint i medicalcateg assessmen in person conditiont tato aanyn age ythat Regis Itr haveation and drugs or medication that I use. FOLD your own records. Additionally, if your patient‘s visual acuity with corrective lenses in the better eye or with both eyes together is worse than 6/12, or SUBURB/TOWN POSTCODE ProviderP HONENumber No. irrespective of the class of licence he•ld bify youtheyearan app dare Litherealiccant. ensinnotft gerfamiliar Cen. Howtreever or Servicewith, if you your cSAonsider Centre patient’s it or pr udmaenil ittfull orto ne medicalPOcess Baroxy 1,yo Wahistoryu mlkeayrv recommenill e,please 5081. d complete a pIractican eitherl d ca rivinallse, gofit a is ssessmentsections re commended a 3,t an 4y t andaghaetyt you 5; keepap a (Not required if a separate report has been provided or a specialist has completed the declaration above). FOLD • provide comment in the notes section on the inner page on how well controlled your patient’s condition(s) are and compliance and Licensing Centre or Service SA CentreISignature consent orcirres maopilypec if torto totive y oumy POor fo t medicalwnBheox clare 1,css Waor ofds.lke practitioner licrvenillce,e he5081.ld b y t heand/orI nap eitherplica myn cat. se, treating it is recommen specialistded th atreleasing you keepap a to the DepartmentDate of Planning, Transport and FOLD FOLD FOLD their visual field is worse than the criteria contained in the Assessing Fitness to Drive guidelines, an Optometrist or Ophthalmologist copy for your own records. • InfrastructureprovidewithApplicants any comment medication whoany holdmedicalin the a taking.licence notes information other section than on arelating basic the “car” opposite to licence my ability pageare required onto drivehow to undergo wellsafely. controlled a practical driving your patient’s assessment condition(s)at age 85 and are and compliance SIGNATURE DATE ...... /...... /...... PleaseAp note:plicants Your who ho medicalld a licence practitioner other than a basic has “ca ar” legal lic ence obligation are required to to u ndinformergo a p theracti calRegistrar driving assessment if they believe at age 85 that and a everyperson they have must complete the Eyesight Certificate. Practice SIGAddressNATURE DATE ...... /...... /...... Applicants who hold a licence other thanwith a baevery anysic “ca yearmedicationr” licen thereafter.ce are req taking; However,uired to und if eryougo considera practical it drivin prudentg assessmen or necessaryt at ag youe 85 may an recommendd every a practical driving assessment at any SpecialistMedical Practitioner’s name: name examined yearage irrespectivetherea is sufferingfter. How of theever from class, if you ofa c licencemedicalonsider held it pr conditionud byen thet or applicant.nec suchessary thatyou m theyay recommen endangerd a practica the publicl driving aifssessment they drove. at any age year thereafter. However, if you consider it prirresudentpec ortive necessary of the cla youss of m liaycen receommen held byd tahe pr aacpplticaical dnt.rivin g assessment at any age Visual acuity Right Left Together FOLD • FOLD section 4 (Eyesight Certificate) must be completed in all cases. Provider Number irrespective of the class of licence held by the applicant.cant. FOLD FOLD Signature Date Type of specialist: A person must not, in providing information, make a statement that is false or misleading. Penalties apply. Uncorrected 6/_____ 6/_____ 6/_____ Telephone Number Facsimile Number E-mail Address Practice Address Please note: Your medical practitioner has a legal obligation to inform the Registrar if they believe that a person they have Corrected (glasses/contacts) 6/_____ 6/_____ 6/_____ Conditions assessed: WHATexamined TO is sufferingDO WITH from THEa medical COMPLETED condition such that MEDICAL they endanger ASSESSMENT the public if they drove. SECTION 3: MEDICAL EXAMINATION REPORT - For all "Y es" answers provide comments on the page opposite. Does your patient meet the eyesight standards in the Assessing Fitness to Drive 2016? No Yes Specialist’s signature: Date: / / A person must not, in providing information, make a statement that is false or misleading. Penalties apply. (refer to vision and eye disorders in “Assessing Fitness to Drive” publication) 1. •BLACKOUT Return to GPO Box 1533, Adelaide 5001 or any Service SA Customer Service7. NEUROLOGICA Centre L / NEUROMUSCULAR CONDITIONS Telephone Number Facsimile Number E-mail Address ISMF Classification when complete - Has your patient experienced a blackout? Does your patient have a neurological / neuromuscular condition? If more than one specialist has undertaken an assessment, please provide your details in the section above or attach a report if applicable. • Enquiries: 13 10 84 Are glasses or contact lenses required for driving? No Yes If Yes, please complete the following. SENSITIVE: MEDICAL - I3 - A3 Date of most recent episode: __ / __ / __ If Yes, please complete the following. Please tick the relevant condition(s): 2. CARDIOVASCULAR DISEASE If you are not completing the other sections of this form please provide your details. Brain Aneurysm Muscular Dystrophy Does your patient have a cardiovascular condition? If Yes, please complete the following. Cerebral Palsy Parkinson’s Disease Please tick the relevant condition(s): Dementia Seizure Epileps*y*** Space-occupying Lesion (brain tumour) Medical Practitioner / Optometrist’s Name Date Coronary Artery Bypass Grafting (CABG) Head Injury Stroke Dilated Cardiomyopathy Multiple Sclerosis Subarachnoid Haemorrhage Heart Failure Cardiac Aneurysm Medical Practitioner / Optometrist’s Signature Provider Number Contact Number Cardiac Arrest Heart Transplant *Date of last episode: __ / __ / __ Cardiac Pacemaker Hypertrophic Cardiomyopathy Congenital Heart Disorder Implantable Cardioverter Defibrillator ADDITIONAL NOTES: Provide comment to each Yes condition(s) below including reference to the specific condition (e.g. 4. Diabetes). Other Cardiovascular: ______8. PSYCHIATRIC CONDITION 3. HYPERTENSION
Does your patient have blood pressure consistently greater than 200 If Yes, please complete the following. systolic or greater than 110 diastolic (treated or untreated)? Please tick the relevant condition(s): Anxiety Post Traumatic Stress Disorder (PTSD) Blood pressure readings: Bipolar Affective Disorder Schizophrenia Systolic: ______Diastolic: ______Chronic Depression Tourette’s Syndrome Personality Disorder Other: ______4. DIABETES Does your patient require medication? No Yes Does your patient have diabetes controlled by medication? If Yes - is your patient compliant with medication?
If Yes, please complete the following. Diabetes controlled by Insulin Tablet 9. SLEEP DISORDER Is your patient compliant with medication ? Does your patient have a sleep disorder? If Yes, please complete the following. Does the patient experience early warning symptoms of hypoglycaemia?
Date of last episode: ______Other: ______Any end organ effects: please specify: ______
10. SUBSTANCE MISUSE 5. HEARING LOSS Does your patient currently misuse alcohol or drugs? Does your patient have severe hearing loss? If yes, complete the following. Refer to ‘Assessing Fitness to Drive’ publication for definition of ‘severe hearing loss’. Alcohol Illicit drugs Prescription drugs 6. MUSCULOSKELETAL CONDITION Does your patient have a musculoskeletal condition? Any end organ effects: (please specify)______If Yes, please complete the following. Please tick the relevant condition(s): Severe Arthritis Other Musculoskeletal Conditions Limb Is the condition likely to affect driving? SECTIONSECTION 2:2: IMPORTANTIMPORTANT NOTESNOTES FORFOR THETHE MEDICALMEDICAL PRACTITIONERPRACTITIONER SECTIONSECTION 4:4: EYESIGHTEYESIGHT CERTIFICATECERTIFICATE (Must(Must be be completed completed in in all all cases) cases) SECTIONSECTION 2:2: IMPORTANTIMPORTANT NOTESNOTES FORFOR THETHE MEDICALMEDICAL PRACTITIONERPRACTITIONER SECTIONSECTION 4:4: EYESIGHTEYESIGHT CERTIFICATECERTIFICATE (Must(Must be be completed completed in in all all cases) cases) TheThe Registrar Registrar of of Motor Motor Vehicles Vehicles requires requires certain certain applicants applicants for for a a driver’s driver’s licence, licence, or or licence licence holders, holders, to to provide provide evidence evidence of of their their fitness fitness 11.11. If If the the patient patient has has one one or or more more of of the the following following eye eye or or vision vision conditions, conditions, please please tick tick condition/s. condition/s. SECTION 2: IMPORTANTSECTION NOTES 2: IMPORTANT FOR THE MEDICAL SECTIONNOTES FOR PRACTITIONER2: IMPORTANT THE MEDICAL SECTIONNOTES PRACTITIONER FOR 2: IMPORTANT THE MEDICAL NOTES PRACTITIONER FORSECTION THE MEDICAL 4: EYESIGHT PRACTITIONERSECTION CERTIFICATE 4: EYESIGHT (Must CERTIFICATEbeSECTION completed 4:in all(MustEYESIGHT cases) be completed CERTIFICATESECTION in all cases) 4: (MustEYESIGHT be completed CERTIFICATE in all cases) (Must be completed in all cases) toto drive. drive. Please: Please: TheThe Registrar Registrar of of Motor Motor Vehicles Vehicles requires requires certain certain applicants applicants for for a a driver’s driver’s licence, licence, or or licence licence holders, holders, to to provide provide evidence evidence of of their their fitness fitness 11.11. If If the the patient patient has has one one or or more more of of the the following following eye eye or or vision vision conditions, conditions, please please tick tick condition/s. condition/s. toto drive. drive. Please: Please: CataractsCataracts DiplopiaDiplopia GlaucomaGlaucoma MacularMacular Degeneration Degeneration •• referrefer to to section section 1 1 that that has has been been completed completed by by your your patient; patient; The Registrar of Motor VehiclesThe Registrar requires certainof Motor applicants Vehicles forrequires aThe driver’s Registrarcertain licence, applicants of Motoror licence for Vehicles aholders, driver’s requires tolicence,The provide Registrarcertain or evidencelicence applicants of Motor holders, of their for Vehicles toaCataracts Cataractsfitness driver’s provide requires licence, evidence certain or licenceof applicants their11. Ifholders, fitness theDiplopia forDiplopiapatient toa driver’s provide has one licence, evidence or11. more orIf thelicenceof of their patientthe Glaucomaholders, Glaucomafollowingfitness has oneto eyeprovide or ormore vision evidence of11. theconditions, If following theof their MacularpatientMacular please fitness eye hasDegeneration Degeneration ortick onevision condition/s. or conditions,more of 11. the pleaseIf following the patient tick condition/s.eye has or onevision or conditions,more of the please following tick condition/s.eye or vision conditions, please tick condition/s. •• referrefer to to section section 1 1 that that has has been been completed completed by by your your patient; patient; PoorPoor Night Night Vision Vision RetinitisRetinitis Pigmentosa Pigmentosa OtherOther condition condition which which may may impair impair their their ability ability to to drive drive (please (please specify) specify) •• referrefer to to the the National National Transport Transport Commi Commis sion'ss sion's publication publication “Assessing “Assessing Fitness Fitness to to Drive Drive 201 20166”” private private standards standardsto drive. for forPlease: light light vehicle vehicle licence. licence.to drive. Please: to drive. Please: to drive. 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CARDIOVASCULAR your PSYCHIATRICyour pressure patient patient readings:experienced experienced CONDITION DISEASE DISEASE(referADDITIONAL(Only a a blackout? blackout? to complete vision8. and NOTES:PSYCHIATRIC eyequestions disorders Provide 11CONDITION in and “Assessingcomment 12 if your toFitness each patient toIfDoes IfDoes Yes, Drive”Yes, Yes your pleasehasyour please publication)condition(s) patienta patient completevision complete have have or below the theaeye a neurologicalfollowing. neurologicalfollowing. disorder,including /reference or/neuromuscular neuromuscular is required to the to condition? specificcondition? wear glassescondition or (e.g. corrective 4. Diabetes)IfIf you you lenses) are are. not not completing completing the the other other sections sections of of this this form form please please provide provide your your details. details. PersonalityPersonality1. Cardiac BLACKOUTCardiac Disorder Disorder Arrest Arrest Other:Other:HeartHeart ______Transplant Transplant Other Cardiovascular:8.7. Brain______BrainPSYCHIATRICNEUROLOGICA Aneurysm Aneurysm Other Cardiovascular:CONDITIONL / NEUROMUSCULARBipolarMuscularMuscular ______Affective Dystrophy Dystrophy CONDITIONS Disorder OtherDate DateCardiovascular:Bipolar of of Schizophreniamost most Affective recent recent ______episode:Disorder episode:ADDITIONALADDITIONAL(refer __ __ Uncorrected to / / __vision __Schizophrenia / / __ __andNOTES: NOTES:Bipolar eye disorders Affective Provide ProvideProvide inDisorder comment “Assessingcomment comment 6/_____ to totoFitness each eacheachSchizophrenia 6/_____ to Drive” Yes YesBipolar condition(s) condition(s)publication)6/_____condition(s) Affective Disorder below belowbelow including includingincludingSchizophrenia reference referencereference to toto the thethe specific specificspecific condition conditioncondition (e.g. (e.g.(e.g. 4. 4.4. 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Yes, HYPERTENSIONDIABETESYes, HYPERTENSIONDIABETES please please complete complete the the following. following. 8.8. Does PSYCHIATRIC Uncorrected PSYCHIATRIC Uncorrected your patient CONDITION CONDITION have a neurological 6/_____ /6/_____ neuromuscular 6/_____ 6/_____ 2.Ifcondition?2.If Yes, CARDIOVASCULAR6/_____Yes, CARDIOVASCULAR6/_____ please please complete complete the DISEASE theDISEASE following. following.Are11. Does Correctedglasses your or (glasses/contacts) patientcontact havelenses one required or more 6/_____for ofdriving? the 6/_____ followingIfIf Yes, CerebralYes,Cerebral please please 6/_____ visionPalsy Palsy complete complete or eye the the disorders?following. following.Parkinson’sParkinson’s Please Disease Disease tick: No Yes IfIf you you are are not not completing completing the the other other sections sections of of this this form form please please provide provide your your details. details. DoesDoesmedicalmedical your your patient conditionspatient conditions have have diabetesand diabetesand all all of controlledof controlled sections sections by 4by 4 and medication? andmedication? 5; 5; IfIf Yes, Yes, Ifplease pleaseYes, please complete complete complete the the following. following. the following.Does yourOther Other patient Cardiovascular: Cardiovascular: have blood ______pressureDoes your consistently patient have greaterDoes VisualDoes PleaseVisualblood your your than Field pressuretickField patient patient 200the Defect Defect relevant require Doesconsistentlyrequire your medication? condition(s):medication? If patient Yes,greater please have than bloodcomplete 200 pressure the following.Date consistentlyDate If No Yes, Noof of most mostplease Yesrecentgreater Yesrecent complete episode: episode:than the 200 following.Are __ __ glasses / / __ __ / / __or If__ Yes, contact please lenses complete required the following. for driving? 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If the DISORDER patient has one or more of the followingAnyAny eyeend end organor organ vision effects: effects: conditions, please please specify:If specify: youplease are ______tick not condition/s.completing the other sections of thisIfIf Yes, Yes, form please please please complete complete provide the the following. following.your details. 3.IfIs3.IfIs Yes, yourHYPERTENSIONCongenital Yes,yourHYPERTENSIONCongenital please patient pleasepatient Heartcomplete compliantHeartcomplete compliant Disorder Disorder the thewith with following. following. medication medication Implantable Implantable ? ? Cardioverter Cardioverter Defibrillator Defibrillator PleasePleaseDiabetes4.Severe SevereDIABETES tick tick Arthritis controlledArthritis the the relevant relevant by condition(s): condition(s): OtherInsulinOther Musculoskeletal Musculoskeletal Tablet Conditions Conditions Brain Aneurysm Muscular Dystrophy LimbLimbto drive. 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Drive’ driving?Drive’ publication publication for for definition definition of of Epileps*y*** Space-occupying Lesion (brain tumour) Medical Practitioner / Optometrist’s Name 10.10. SUBSTANCE SUBSTANCE MISUSE MISUSE Date AnxietyAnxietyOther:Other:SevereSevere ______Arthritis Arthritis OtherOtherPostPost Musculoskeletal Musculoskeletal TraumaticCoronary Traumatic Artery Stress Stress Conditions Conditions Bypass Disorder Disorder Grafting (PTSD) (PTSD) (CABG) 9. SLEEPAlcohol Alcohol DISORDER 5.ReferAny5.ReferAny HEARING HEARING end endto to ‘Assessing organ ‘Assessingorgan LOSS LOSS effects: effects: Fitness Fitness please please to to Drive’specify: Drive’specify: publication publication ______for for definition definition of of / / BDoesBDoesloodlood your pressure yourpressure patient patient readings: readings: have have blood blood pressure pressure consistently consistently greater greater than than 200 200 Multiple Multiple‘severe‘severeDiabetesDate Sclerosis ofSclerosis hearing hearinglast controlled episode: loss’. loss’. by ______Subarachnoid SubarachnoidInsulin TabletHaemorrhage Haemorrhage 10.9. HeadSLEEP SUBSTANCEVisual Injury DISORDER Field MISUSE Defect DoesDoesAlcoholAlcohol your your patient patient currently currently misuse misuse alcohol alcohol or or drugs? drugs? 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ChronicSLEEP ChronicSLEEPDoesAny tick tick Depression DISORDER Depressionend DISORDERtheyour the organ relevant relevant patient effects: condition(s): havecondition(s): please severe specify:Tourette’s Tourette’shearing ______Syndromeloss? Syndrome If Yes,yes, MultipleNote: completeplease If Sclerosis the complete the patient following. the has following. oneSubarachnoid or more of Haemorrhage the above5.Refer5.Refer HEARING conditionsHEARING to to ‘Assessing ‘Assessing LOSS LOSS and Fitness Fitnessthe eyesight to to Drive’ Drive’ publication standardspublication for forare definition definition not met of of (aided) an Optometrist • if you are familiar with your patient's full medical history, you only10.10. need SUBSTANCE SUBSTANCEDoes to Cardiac complete the patient Aneurysm MISUSE MISUSE theexperience parts ofearly section warningHeart 3 relevantsymptomsFailure toof hypoglycaemia?the patient's If yes,PrescriptionPrescription complete drugs thedrugs following. DoesDoesPrescriptionAlcoholPrescriptionAlcohol your your patient patient drugs drugs currently currently misuse misuse alcohol alcohol or or drugs? drugs? 5.5. HEARING HEARING LOSS LOSS *DDoes*DDoesateateIs IsyourofReferDoes yourofthe thelast last condition patient conditionthetopatient episode: episode:‘Assessing patient have havelikely likely experience __a __Fitnesstoa sleepto sleep affect/ affect/ __ __ disorder? to /disorder?driving? early /driving? __Drive’ __ warning publication symptoms for definition of hypoglycaemia? of or Ophthamologist must complete the Eyesight‘severe Certificate.‘severe hearing hearing loss’. loss’. Medical Practitioner / Optometrist’s Signature Provider Number Contact Number IsIs yourCardiac yourCardiac patient patient Pacemaker Pacemaker compliant compliant with with medication medicationHypertrophicHypertrophic ? ? 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MUSCULOSKELETAL MUSCULOSKELETAL CONDITION CONDITION IllicitIllicit drugs drugs Does4.Does4. DIABETES DIABETES your your patient patient have have severe severe hearing hearing loss? loss? IfIf yes, Bipolaryes,Bipolar 5.‘severecomplete complete HEARING Affective Affective hearing the the Disorder LOSSfollowing.Disorder following. loss’. SchizophreniaSchizophrenia Does your patient currently misuse alcohol or drugs? ReferRefer to to ‘Assessing ‘Assessing Fitness Fitness to to Drive’Signature Drive’ publication publication for for definition definition of of Signature Contact Number DoesDoesCongenitalCongenital the the patient patient Heart Heart experience experience Disorder Disorder early early warning warning Implantable Implantable symptoms symptoms Cardioverter Cardioverter of of hypoglycaemia? hypoglycaemia? 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PrescriptionPrescription drugs drugs Systolic:DoesSystolic:Does your your ______patient patient have have diabetes diabetes controlled controlled Diastolic: Diastolic: by by medication? ______medication?______ChronicChronicAlcoholIfAlcoholIf DateYes, Yes, Depression Depression pleaseof please last episode:complete complete ______the the following. following.Tourette’sTourette’s Syndrome Syndrome If yes,Other: complete ______the following. ‘severe‘severe hearing hearing loss’. loss’. If If Yes Yes -Refer -is is your your to patient‘Assessing patient compliant compliant Fitness with with to Drive’medication? medication? publication for definition of theirOther:Prescription visual ______drugsfield is worse than the criteria contained If6.If6. Yes, MUSCULOSKELETALYes, MUSCULOSKELETAL pleasein please the completeAssessing complete the the CONDITION Fitness CONDITIONfollowing. following. to Drive guidelines, an Optometrist or OphthalmologistIllicitIllicit drugs drugs • provide comment in the notes section on the opposite page on how wellAny controlledCongenital end organ Heart youreffects: Disorder patient’s please specify: condition(s) Implantable ______are Cardioverter and compliance Defibrillator ADDITIONALADDITIONALAlcoholPrescription NOTES: NOTES: drugs Provide Provide comment comment to to each each Yes Yes condition(s) condition(s) below below including including reference reference to to the the specific specific condition condition (e.g. (e.g. 4. 4. Diabetes) Diabetes).. DateDate of of last last episode: episode: ______8.8. PSYCHIATRICPersonality PSYCHIATRICPersonalityIllicitPleaseIllicitPlease6.‘severeAny MUSCULOSKELETALdrugs drugs end tick tickhearingDisorder Disorderorgan the theCONDITION CONDITION relevant effects:relevantloss’. please condition(s): condition(s): CONDITION specify:Other:Other: ______mustAlcohol complete the Eyesight Certificate. AnyAny end end organ organ effects: effects: (please (please specify) specify)______IfIf Yes, Yes, please please complete complete the the following. following. Other Other Cardiovascular: Cardiovascular: ______Other:Other:6. MUSCULOSKELETAL ______CONDITION DoesPleaseDoesPlease your your tick tick patient patientthe the relevant relevant have have a a musculoskeletalcondition(s): musculoskeletalcondition(s): condition? condition? PrescriptionPrescription drugs drugs 4.4. DIABETES DIABETESwith any medication taking; Any Illicitend organdrugs effects: (please specify)______ADDITIONAL NOTES: Provide comment to each Yes condition(s) below including reference to the specific condition (e.g. 4. Diabetes). 3.Any3.Any HYPERTENSION HYPERTENSION end end organ organ effects: effects: please please specify: specify: ______DoesDoesPrescription PrescriptionyourDoes yourSevereSevere patient patientyour Arthritis Arthritisdrugspatient drugsrequire require have medication? medication? a musculoskeletalOtherOther Musculoskeletal Musculoskeletal condition? Conditions Conditions No No Yes Yes 8.10.Any PSYCHIATRIC SUBSTANCE end organ effects: MISUSECONDITION (please specify)______If6.If6. Yes, MUSCULOSKELETALSevereYes, MUSCULOSKELETALSevere please please Arthritis Arthritis complete complete the the CONDITION CONDITIONfollowing. following.OtherOtherADDITIONAL Musculoskeletal Musculoskeletal NOTES: Conditions Conditions Provide comment to each Yes condition(s) below including reference to the specific condition (e.g. 4. Diabetes). DiabetesDiabetes controlled controlled by by Insulin Insulin Tablet Tablet 9. 9. SLEEP SLEEPDoes5. HEARING DISORDER DISORDERyour patient LOSS have a musculoskeletal Other condition? Cardiovascular: ______8. PSYCHIATRICVisualPrescription acuity drugs CONDITION Right Left Together 6.Does6.Does MUSCULOSKELETAL MUSCULOSKELETAL •your yoursection patient patient 4 have(Eyesight have diabetes CONDITION diabetesCONDITION Certificate) controlled controlled must by by medication? medication? be completed in all cases. If5. Yes, HEARING please LOSScomplete the following. Other Cardiovascular: ______DoesPrescription your patient drugs currently misuse alcohol or drugs? AnyAny end end organ organ effects: effects: (please (please specify) specify)______DoesDoes your your patient patient have have blood blood pressure pressure consistently consistently greater greater than than 200 200 IfDoesIfDoes Yes Yes -IfyourDoes -your isLimb Yes,isLimb your your patient yourpatientplease patient patient patient have completehave compliant compliant a havea sleep sleep the severe with withdisorder?following. disorder? medication? medication? hearing loss? Does your patient currently misuse alcohol or drugs? DoesPleaseDoesPlease your your tick tick patient patientthe the relevant relevant have have a a musculoskeletalcondition(s): musculoskeletalcondition(s): condition? condition? IsIs your your patient patient compliant compliant with with medication medication ? ? IfAny10.IfAny10. Yes, Yes, SUBSTANCE endSUBSTANCE end 6.Does3.please please MUSCULOSKELETALorganHYPERTENSION organ your complete completeeffects: effects: patientMISUSE MISUSE (please the(please the have following. following. specify) severespecify)CONDITION ______hearing______loss? If yes, complete the following. LimbLimb Does5.systolicDoes5.systolic HEARING HEARING your your or orpatient patientgreater greaterLOSS LOSS have have than than a a musculoskeletal 110musculoskeletal 110 diastolic diastolic (treated (treated condition? condition? or or untreated)? untreated)? IfIf Yes, Yes,Please please please tickcomplete complete the relevant the the following. following. condition(s): If yes, complete Uncorrected the following. 6/_____ 6/_____IfIf Yes, SevereYes,Severe please please 6/_____ Arthritis Arthritis complete complete the the following. following.OtherOther Musculoskeletal Musculoskeletal Conditions Conditions IfIf Yes, Yes, please please complete complete the the following. following. DoesDoesIs IsyourPleaseReferDoes yourthe the condition patient conditiontoyourpatient tick ‘Assessing patientthe currently currentlylikely likely relevant haveFitnessto to affect misuseaffect misuse condition(s):blood to driving? driving? Drive’ alcoholpressure alcohol publication or or consistently drugs? drugs? for definition greater of than 200 Any end organ effects: (please specify)______IsIs the the condition condition likely likely to to affect affect driving? driving? IfDoesIfDoes Yes, Yes, the your pleasethe yourplease patient patient patient patient complete complete experience experience have have the thesevere severe following. following.early early hearing hearingwarning warning loss? symptomsloss? symptoms of of hypoglycaemia? hypoglycaemia? PleasePleaseDoes tick tick your the yourthe relevant patientrelevant patient have condition(s): havecondition(s): a musculoskeletal blood pressure condition? consistently greater than 200 IfAny Yes, Alcoholend please organ complete effects: (please the following. specify)______If If yes, yes, ‘severesystoliccomplete completeSevere hearing or theArthritis the greater following. following. loss’. than 110 Otherdiastolic Musculoskeletal (treated or untreated)? Conditions Alcohol Corrected (glasses/contacts) 6/_____ 6/_____PleasePlease tick tick 6/_____ the the relevant relevant condition(s): condition(s): DiabetesDiabetes controlled controlled by by Insulin Insulin Tablet Tablet 9.9. AnxietySLEEP AnxietySLEEPIfsystolic Yes, DISORDER DISORDER please or greater complete than the 110 following. diastolicPostPost Traumatic Traumatic (treated Stress Stressor untreated)? Disorder Disorder (PTSD) (PTSD) LimbLimb PleaseReferPleaseRefer to totick ‘Assessingtick ‘Assessing the the relevant relevant Fitness Fitness condition(s): condition(s): to to Drive’ Drive’ publication publication for for definition definition of of PleaseIllicit tick drugs the relevant condition(s): SevereSevere Arthritis Arthritis OtherOther Musculoskeletal Musculoskeletal Conditions Conditions BBloodlood pressure pressure readings: readings: Does Does Alcohol Alcohol Pleaseyour yourLimb patient patient tick the have have relevant a a sleep sleep condition(s): disorder? disorder? Please tick the relevant condition(s): IsIs the the condition condition likely likely to to affect affect driving? driving? ‘severeIs‘severeIs Severeyour SevereyourSECTION patienthearing patienthearing Arthritis Arthritis compliant compliantloss’. loss’. 3: with withMEDICAL Othermedication Othermedication Musculoskeletal Musculoskeletal ? ? EXAMINATION Conditions Conditions REPORT - BipolarForBipolarPlease allLimb Affective Affective"Y tick es" the Disorderanswers Disorder relevant providecondition(s):SchizophreniaSchizophrenia comments on the page opposite. DoesPrescription your patient drugs meet the eyesight standards in the Assessing Fitness to Drive 2016? No DateDate of of last last episode: episode: ______If If Yes, Yes,Other:Other: please please ______complete complete the the following. following. AnxietyPrescription drugs Post Traumatic Stress Disorder (PTSD) Yes Systolic:Systolic: ______Diastolic: Diastolic: ______IllicitIllicitIsBlood the Severedrugs drugs condition pressure Arthritis likely readings: to affect Otherdriving? Musculoskeletal Conditions LimbLimb DoesDoes the the patient patient experience experience early early warning warning symptoms symptoms of of hypoglycaemia? hypoglycaemia? ChronicChronic6.Blood MUSCULOSKELETALSevere Depression Depression pressure Arthritis readings: CONDITIONOtherTourette’sTourette’s Musculoskeletal Syndrome Syndrome Conditions Bipolar(refer to Affective vision and Disorder eye disorders inSchizophrenia “Assessing Fitness to Drive” publication) AnyAnyLimbLimb end end1. BLACKOUTorgan organ effects: effects: please please specify: specify: ______Prescription Prescription7. NEUROLOGICA drugs drugs L / NEUROMUSCULAR CONDITIONS Bipolar Affective Disorder Schizophrenia IsIs the the condition condition likely likely to to affect affect driving? driving? PersonalityPersonalitySystolic:DoesLimb your Disorder Disorder______patient have a musculoskeletalOther:Other: ______Diastolic: condition? ______Any end organ effects: (please specify)______6.Is6.Is theMUSCULOSKELETAL theMUSCULOSKELETAL conditionHas condition your likely patientlikely to to affect experiencedaffect CONDITION CONDITION driving? driving? a blackout? Systolic:DoesLimb youryour ______patient patient have have a musculoskeletal a neurological Diastolic: / condition? neuromuscular ______condition? Chronic Depression Tourette’s Syndrome 4.4. DIABETES DIABETES 10.10. SUBSTANCE SUBSTANCEIf Yes, please MISUSE MISUSE complete the following. Are glasses or contact lenses required for driving? No Yes 5.Date5.Date HEARING HEARING of Ifof Yes,last last episode: pleaseepisode:LOSS LOSS complete ______the following. DoesDoes yourIsIf your Yes,the patient patientcondition please require require complete likely medication? medication? to theaffect following. driving? No No Yes Yes Personality Disorder Other: ______DoesDoes your your patient patient have have a a musculoskeletal musculoskeletal condition? condition? DoesAny DoesAny Other:end Other: endyour your organ organ ______patient______patient effects: effects: currently currently (please (please misuse misusespecify) specify) alcohol ______alcohol______or or drugs? drugs? Personality Disorder Other: ______DoesDoes your your patient patient have have severediabetes severediabetes hearing hearing controlled controlled loss? loss? by by medication? medication? Please4. DIABETES tick the relevant condition(s): IfAnyIf AnyYes, Yes, end end please please organ organ complete completeeffects: effects: please the pleasethe following. following. specify: specify: ______IfIf Yesyes, Yesyes, -PleaseIf4. complete - iscomplete Yes, isDIABETES your your please tick patient patient the the the following.complete following. compliantrelevant compliant the condition(s): with withfollowing. medication? medication? Date of most recent episode: __ / __ / __ Does your patient require medication? No Yes ReferRefer to to ‘Assessing ‘Assessing Fitness Fitness to to Drive’ Drive’ publication publication for for definition definition of of DoesSevere your Arthritis patient have diabetesOther controlledMusculoskeletal by medication? Conditions Please‘severeIfPlease‘severeIf Yes, Yes, please tickhearingplease tickhearing the the complete complete loss’.relevant loss’.relevant the thecondition(s): condition(s): following. following. 10.10. SUBSTANCEAlcohol SUBSTANCEAlcoholPleaseDoes your tick patientMISUSEthe MISUSE relevant have condition(s):diabetes controlled by medication? If Yes - is your patient compliant with medication? 5.5. HEARING HEARING2. CARDIOVASCULAR LOSS LOSS DISEASE Limb If you are not completing the other sections of this form please provide your details. DiabetesDiabetesSevereSevere controlled Arthritis controlledArthritis by by Insulin InsulinOther Other Musculoskeletal Musculoskeletal Tablet Tablet Conditions Conditions Does9.Does9. SLEEP SLEEPIllicitIllicit your your Limbdrugs drugsDISORDER DISORDERpatient patient currently currently misuse misuse alcohol alcohol or or drugs? drugs? DoesDoes your your patient patient have have severe severe hearing hearing loss? loss? If Yes,Brain please Aneurysm complete the following.MuscularParkinson’s Dystrophy Disease Does your patient have a cardiovascular condition? IfDoesIfDoes yes, yes,PrescriptionPrescription Isyour complete yourcomplete the patient conditionpatient thedrugs thedrugs have following. havefollowing. likely a a sleepto sleep affect disorder? disorder? driving? ReferIsReferIs Limbyour Limbyour toIf topatient Yes,patient‘Assessing ‘Assessing please compliant compliant Fitness completeFitness with with to to medication theDrive’ medicationDrive’ following. publication publication ? ? for for definition definition of of DiabetesCerebral controlled Palsy by Insulin Parkinson’s TabletSeizure Disease 9. SLEEP DISORDER 6.6. MUSCULOSKELETAL MUSCULOSKELETAL CONDITION CONDITION IfIf Yes, Yes,AlcoholAlcohol Diabetesplease please complete complete controlled the the by following. following. Insulin Tablet 9. SLEEP DISORDER Is‘severeDoesIs‘severeDoes the the conditionthe conditionthe hearing hearing patient patient likelyloss’. likelyloss’.experience experience to to affect affect early driving?early driving? warning warning symptoms symptoms of of hypoglycaemia? hypoglycaemia? Date of last episode: __ / __ / __ Does your patient have a sleep disorder? Please tick the relevant condition(s): Any Any end endIs Dementiayourorgan organ patient effects: effects: compliant (please (please specify) withspecify) medication______Seizure______? Does your patient have a sleep disorder? DoesDoes your your patient patient have have a a musculoskeletal musculoskeletal condition? condition? IllicitIllicit drugs drugs If Yes, please complete the following. DoesEpilepsyEpileps*y*** the patient experience earlySpace-occupying warningSpace-occupying symptoms Lesion of hypoglycaemia? (brain Lesion tumour) Medical Practitioner / Optometrist’s Name Date IfIf Yes, Yes, please please complete complete the the following. following. Coronary Artery Bypass Grafting (CABG) Prescription PrescriptionDoes the patientdrugs drugs experience early warning symptoms of hypoglycaemia? Date of last episode: __ / __ / __ (brain tumour) 6.PleaseDate6.PleaseDate MUSCULOSKELETAL MUSCULOSKELETAL of of tick last ticklast theepisode: theepisode: relevant relevant ______condition(s): CONDITIONcondition(s): CONDITION Other:Other:Head ______Injury Stroke Dilated Cardiomyopathy Stroke AnyAnySevereSevere end end organ organArthritis Arthritis effects: effects: please pleaseOther specify:Other specify: Musculoskeletal Musculoskeletal ______Conditions Conditions AnyAny end endDate HeadMultipleorgan organ of last Injuryeffects: effects: Sclerosis episode: (please (please ______specify) specify)______Subarachnoid______Haemorrhage DoesDoes your your Cardiac patient patient Aneurysmhave have a a musculoskeletal musculoskeletal condition? condition?Heart Failure Date of last episode: ______Date of last episode: __ / __ / __ Other: ______IfIf Yes, Yes, please please complete complete the the following. following. Multiple Sclerosis Medical Practitioner / Optometrist’s Signature Provider Number Contact Number LimbLimb 10.10. SUBSTANCE SUBSTANCEAny end organ MISUSE MISUSE effects: please specify: ______Subarachnoid Haemorrhage 5.5. HEARING HEARING Cardiac LOSS LOSS Arrest Heart Transplant PleasePlease tick tick the the relevant relevant condition(s): condition(s): DoesDoes your yourMuscular patient patient Dystrophy currently currently misuse misuse alcohol alcohol or or drugs? drugs? IsIs the the condition condition likely likely to to affect affect driving? driving? *Date of last episode: __ / __ / __ Date of last episode: __ / __ / __ 10. SUBSTANCE MISUSE DoesDoes your yourCardiac patient patient Pacemaker have have severe severe hearing hearing loss? loss?Hypertrophic Cardiomyopathy IfIf yes, yes, complete complete the the following. following. 10. SUBSTANCE MISUSE SevereSevere Arthritis Arthritis OtherOther Musculoskeletal Musculoskeletal Conditions Conditions 5. HEARING LOSS ReferRefer to to ‘Assessing ‘Assessing Fitness Fitness to to Drive’ Drive’ publication publication for for definition definition of of Other (please specify) Does your patient currently misuse alcohol or drugs? Congenital Heart Disorder Implantable Cardioverter Defibrillator AlcoholAlcoholDoes your patient have severe hearing loss? ‘severe‘severeLimbLimb hearing hearing loss’. loss’. Does your patient have severe hearing loss? If yes, complete the following. IllicitIllicitRefer drugs drugs to ‘Assessing Fitness to Drive’ publication for definition of ADDITIONAL NOTES: Provide comment to each Yes condition(s) below including reference to the specific condition (e.g. 4. Diabetes). IsIs the the condition condition likely likely to to affect affect driving? driving? Alcohol Other Cardiovascular: ______8.‘severe PSYCHIATRIC hearing loss’. CONDITION PrescriptionPrescription drugs drugs Illicit drugs 3. HYPERTENSION Illicit drugs 6.6. MUSCULOSKELETAL MUSCULOSKELETAL CONDITION CONDITION Prescription drugs Does your patient have blood pressure consistently greater than 200 AnyAny end endIf Yes, organ organ please effects: effects: complete (please (please the specify) specify) following.______DoesDoes your your patient patient have have a a musculoskeletal musculoskeletal condition? condition? 6. MUSCULOSKELETAL CONDITION IfIf Yes, Yes, systolicplease please complete completeor greater the the than following. following. 110 diastolic (treated or untreated)? PleaseDoes your tick patient the relevant have a musculoskeletalcondition(s): condition? Any end organ effects: (please specify)______PleasePlease tick tick the the relevant relevant condition(s): condition(s): Does your patient have a musculoskeletal condition? If Yes,Anxiety please complete the following. Post Traumatic Stress Disorder (PTSD) SevereSevereBlood Arthritis Arthritis pressure readings:OtherOther Musculoskeletal Musculoskeletal Conditions Conditions PleaseBipolar tick Affective the relevant Disorder condition(s):Schizophrenia LimbLimbSystolic: ______Diastolic: ______ChronicSevere DepressionArthritis Other MusculoskeletalTourette’s Syndrome Conditions IsIs the the condition condition likely likely to to affect affect driving? driving? Personality Disorder Other: ______Limb 4. DIABETES DoesIs the yourcondition patient likely require to affect medication? driving? No Yes Does your patient have diabetes controlled by medication? If Yes - is your patient compliant with medication?
If Yes, please complete the following. Diabetes controlled by Insulin Tablet 9. SLEEP DISORDER Is your patient compliant with medication ? Does your patient have a sleep disorder? If Yes, please complete the following. Does the patient experience early warning symptoms of hypoglycaemia?
Date of last episode: ______Other: ______Any end organ effects: please specify: ______
10. SUBSTANCE MISUSE 5. HEARING LOSS Does your patient currently misuse alcohol or drugs? Does your patient have severe hearing loss? If yes, complete the following. Refer to ‘Assessing Fitness to Drive’ publication for definition of ‘severe hearing loss’. Alcohol Illicit drugs Prescription drugs 6. MUSCULOSKELETAL CONDITION Does your patient have a musculoskeletal condition? Any end organ effects: (please specify)______If Yes, please complete the following. Please tick the relevant condition(s): Severe Arthritis Other Musculoskeletal Conditions Limb Is the condition likely to affect driving? SECTIONSECTION 2:2: IMPORTANTIMPORTANT NOTESNOTES FORFOR THETHE MEDICALMEDICAL PRACTITIONERPRACTITIONER SECTIONSECTION 4:4: EYESIGHTEYESIGHT CERTIFICATECERTIFICATE (Must(Must be be completed completed in in all all cases) cases) SECTIONSECTION 2:2: IMPORTANTIMPORTANT NOTESNOTES FORFOR THETHE MEDICALMEDICAL PRACTITIONERPRACTITIONER SECTIONSECTION 4:4: EYESIGHTEYESIGHT CERTIFICATECERTIFICATE (Must(Must be be completed completed in in all all cases) cases) TheThe Registrar Registrar of of Motor Motor Vehicles Vehicles requires requires certain certain applicants applicants for for a a driver’s driver’s licence, licence, or or licence licence holders, holders, to to provide provide evidence evidence of of their their fitness fitness 11.11. If If the the patient patient has has one one or or more more of of the the following following eye eye or or vision vision conditions, conditions, please please tick tick condition/s. condition/s. 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Cardiac BLACKOUTCardiac Disorder Disorder Arrest Arrest Other:Other:HeartHeart ______Transplant Transplant Other Cardiovascular:8.7. Brain______BrainPSYCHIATRICNEUROLOGICA Aneurysm Aneurysm Other Cardiovascular:CONDITIONL / NEUROMUSCULARBipolarMuscularMuscular ______Affective Dystrophy Dystrophy CONDITIONS Disorder OtherDate DateCardiovascular:Bipolar of of Schizophreniamost most Affective recent recent ______episode:Disorder episode:ADDITIONALADDITIONAL(refer __ __ Uncorrected to / / __vision __Schizophrenia / / __ __andNOTES: NOTES:Bipolar eye disorders Affective Provide ProvideProvide inDisorder comment “Assessingcomment comment 6/_____ to totoFitness each eacheachSchizophrenia 6/_____ to Drive” Yes YesBipolar condition(s) condition(s)publication)6/_____condition(s) Affective Disorder below belowbelow including includingincludingSchizophrenia reference referencereference to toto the thethe specific specificspecific condition conditioncondition (e.g. (e.g.(e.g. 4. 4.4. 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PleaseIf Yes,Other:PrescriptionOther:Prescription please tick ______the complete drugs relevantdrugs the condition(s): following. DateDate of of last last episode: episode: ______Other: Other: ______DoesDiabetesDoesDiabetes your your controlled controlled patient patient haveby haveby a a cardiovascular Insulincardiovascular Insulin Other Other Tablet TabletCardiovascular: condition?Cardiovascular: condition? ______2.Does CARDIOVASCULAR the patient experience DISEASE earlySevere warning Arthritis symptoms of hypoglycaemia?Other SevereMusculoskeletal Arthritis ConditionsPersonalityOther Musculoskeletal DisorderSevere ArthritisConditionsOther: ______Other MusculoskeletalIsIs your your patient patient Conditions compliant compliant with with medication Ifmedication you are ? ?not completing the other sections of thisDoesDoes form your your please patient patient providehave have a a sleep sleepyour disorder? disorder?details. 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If the DISORDER patient has one or more of the followingAnyAny eyeend end organor organ vision effects: effects: conditions, please please specify:If specify: youplease are ______tick not condition/s.completing the other sections of thisIfIf Yes, Yes, form please please please complete complete provide the the following. following.your details. 3.IfIs3.IfIs Yes, yourHYPERTENSIONCongenital Yes,yourHYPERTENSIONCongenital please patient pleasepatient Heartcomplete compliantHeartcomplete compliant Disorder Disorder the thewith with following. following. medication medication Implantable Implantable ? ? Cardioverter Cardioverter Defibrillator Defibrillator PleasePleaseDiabetes4.Severe SevereDIABETES tick tick Arthritis controlledArthritis the the relevant relevant by condition(s): condition(s): OtherInsulinOther Musculoskeletal Musculoskeletal Tablet Conditions Conditions Brain Aneurysm Muscular Dystrophy LimbLimbto drive. 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Conditions Conditions 10.10.If Yes, CerebralSUBSTANCE SUBSTANCE Cataracts please Palsy complete MISUSE MISUSE the following. Parkinson’s Diplopia Disease Glaucoma Macular Degeneration 10.10. SUBSTANCE SUBSTANCE MISUSE MISUSE 4.4. DIABETES DIABETES If If Yes, Yes, 5.5. IfDateDoesplease HEARING please Yes,HEARING of your please completelast complete patientepisode:LOSS LOSS complete the the have following. ______following. the diabetes following.Is the condition controlled likely by medication?to affect driving?Is the condition likely toADDITIONALADDITIONAL affectIfIf YesYes, driving? - pleaseis your NOTES: completeNOTES:patient Is the compliant conditionProvidethe Provide following. with likelycomment comment medication? to affect to to driving?each each Yes Yes condition(s) condition(s) below below including including reference reference to to the the specific specific condition condition (e.g. (e.g. 4. 4. 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HYPERTENSION HYPERTENSION• refer to the National Transport Commis sion's publication “AssessingIfIf Yes Head YesFitnessHeadPlease Please-IfAny -is Yes,isInjury Injuryyour yourend to tick pleasetick patient Drive organpatient the the complete relevant effects:201compliantrelevant compliant6” please privatethecondition(s): condition(s): with with Strokefollowing.StrokeIs specify:medication? themedication? standards condition ______forlikely light to affect vehicle driving? licence. Epileps*y*** Medical Practitioner / Optometrist’s Name If If yes, yes,Other:Other: complete complete ______the the following. following. Date DateDate of of last last episode: episode: ______DilatedDilated Cardiomyopathy Cardiomyopathy IsReferIsRefer the the conditionto conditionto ‘Assessing ‘Assessing likely likely Fitness Fitnessto to affect affect to to driving? Drive’ driving?Drive’ publication publication for for definition definition of of Epileps*y*** Space-occupying Lesion (brain tumour) Medical Practitioner / Optometrist’s Name 10.10. SUBSTANCE SUBSTANCE MISUSE MISUSE Date AnxietyAnxietyOther:Other:SevereSevere ______Arthritis Arthritis OtherOtherPostPost Musculoskeletal Musculoskeletal TraumaticCoronary Traumatic Artery Stress Stress Conditions Conditions Bypass Disorder Disorder Grafting (PTSD) (PTSD) (CABG) 9. SLEEPAlcohol Alcohol DISORDER 5.ReferAny5.ReferAny HEARING HEARING end endto to ‘Assessing organ ‘Assessingorgan LOSS LOSS effects: effects: Fitness Fitness please please to to Drive’specify: Drive’specify: publication publication ______for for definition definition of of / / BDoesBDoesloodlood your pressure yourpressure patient patient readings: readings: have have blood blood pressure pressure consistently consistently greater greater than than 200 200 Multiple Multiple‘severe‘severeDiabetesDate Sclerosis ofSclerosis hearing hearinglast controlled episode: loss’. loss’. by ______Subarachnoid SubarachnoidInsulin TabletHaemorrhage Haemorrhage 10.9. HeadSLEEP SUBSTANCEVisual Injury DISORDER Field MISUSE Defect DoesDoesAlcoholAlcohol your your patient patient currently currently misuse misuse alcohol alcohol or or drugs? drugs? AnyIfAnyIf Yes, Yes, end end please please organ organ complete completeeffects: effects: please theplease the following. following. specify: specify: ______IfIf Yes, BipolarYes,Bipolar Dateplease please Affective Affective of completelast complete episode: Disorder Disorder the the following. ______following.SchizophreniaSchizophrenia 10. Head SUBSTANCEOther: Injury ______MISUSE Stroke ‘severe‘severe hearing hearing loss’. loss’. Medical Practitioner name Optometrist/Ophthalmologist name Date systolicsystolic Cardiac Cardiac or or Aneurysm greaterAneurysm greater than than 110 110 diastolic diastolicHeartHeart (treated (treated Failure Failure or or untreated)? untreated)? 5. HEARING LOSS Dilated Cardiomyopathy Does IllicitOther:Illicit your drugs drugs ______patient have a sleep disorder? DoesDoes your your patient patient have have severe severe hearing hearing loss? loss? IfIf yes, yes, complete complete the the following. following. (your assessment must be undertaken in accordance with the guidelines);IsAnyDateLimb Limbyour end of patientlast organ severe complianteffects: hypoglycaemic please with medication specify: episodeDilated ______? ifCardiomyopathy applicable: __ / __ / __ MedicalMedicalDoes Multiple yourPractitioner Practitioner Sclerosis patient currently / /O Opptotom mmisuseeetrtSubarachnoidirsits’ts ’alcohol sS Signatureignature or Haemorrhage drugs? ProviderProvider Number Number ContactContact Number Number 10.10. SUBSTANCEIllicit SUBSTANCEIllicit drugs drugs MISUSE MISUSE Systolic:DiabetesSystolic:Diabetes Cardiac Cardiac ______controlled ______controlledArrest Arrest by by Insulin Insulin Heart Heart Diastolic: Diastolic:Tablet TabletTransplant Transplant ______Please9.Please9. ChronicSLEEP ChronicSLEEPDoesAny tick tick Depression DISORDER Depressionend DISORDERtheyour the organ relevant relevant patient effects: condition(s): havecondition(s): please severe specify:Tourette’s Tourette’shearing ______Syndromeloss? Syndrome If Yes,yes, MultipleNote: completeplease If Sclerosis the complete the patient following. the has following. oneSubarachnoid or more of Haemorrhage the above5.Refer5.Refer HEARING conditionsHEARING to to ‘Assessing ‘Assessing LOSS LOSS and Fitness Fitnessthe eyesight to to Drive’ Drive’ publication standardspublication for forare definition definition not met of of (aided) an Optometrist • if you are familiar with your patient's full medical history, you only10.10. need SUBSTANCE SUBSTANCEDoes to Cardiac complete the patient Aneurysm MISUSE MISUSE theexperience parts ofearly section warningHeart 3 relevantsymptomsFailure toof hypoglycaemia?the patient's If yes,PrescriptionPrescription complete drugs thedrugs following. DoesDoesPrescriptionAlcoholPrescriptionAlcohol your your patient patient drugs drugs currently currently misuse misuse alcohol alcohol or or drugs? drugs? 5.5. HEARING HEARING LOSS LOSS *DDoes*DDoesateateIs IsyourofReferDoes yourofthe thelast last condition patient conditionthetopatient episode: episode:‘Assessing patient have havelikely likely experience __a __Fitnesstoa sleepto sleep affect/ affect/ __ __ disorder? to /disorder?driving? early /driving? __Drive’ __ warning publication symptoms for definition of hypoglycaemia? of or Ophthamologist must complete the Eyesight‘severe Certificate.‘severe hearing hearing loss’. loss’. Medical Practitioner / Optometrist’s Signature Provider Number Contact Number IsIs yourCardiac yourCardiac patient patient Pacemaker Pacemaker compliant compliant with with medication medicationHypertrophicHypertrophic ? ? Cardiomyopathy Cardiomyopathy DoesDoesPersonalityAnxietyPersonalityAnxiety6. 6.yourRefer yourMUSCULOSKELETAL MUSCULOSKELETAL patient topatient Disorder ‘AssessingDisorder currently currently Fitness misuse misuseCONDITION CONDITION to Drive’ PostOther:alcohol PostOther:alcohol Traumaticpublication Traumatic ______or or drugs? drugs? Stress forStress definition Disorder Disorder of (PTSD) (PTSD) 10. SUBSTANCE Alcohol MISUSE DoesDoes your your patient patient have have severe severeMedical hearing hearing Practitioner loss? loss? / Optometrist’s Signature IfIf yes, yes, complete complete the the following. following.Provider Number Contact Number BBloodlood pressure pressuremedical readings: readings: conditions and all of sections 4 and 5; IfIf Yes, Yes, 5.‘severeplease please HEARINGCardiac hearingcomplete complete Arrest LOSS loss’. the the following. following. Heart Transplant 10. SUBSTANCEAlcohol MISUSE 6.6. MUSCULOSKELETAL MUSCULOSKELETAL CONDITION CONDITION IllicitIllicit drugs drugs Does4.Does4. DIABETES DIABETES your your patient patient have have severe severe hearing hearing loss? loss? IfIf yes, Bipolaryes,Bipolar 5.‘severecomplete complete HEARING Affective Affective hearing the the Disorder LOSSfollowing.Disorder following. loss’. SchizophreniaSchizophrenia Does your patient currently misuse alcohol or drugs? ReferRefer to to ‘Assessing ‘Assessing Fitness Fitness to to Drive’Signature Drive’ publication publication for for definition definition of of Signature Contact Number DoesDoesCongenitalCongenital the the patient patient Heart Heart experience experience Disorder Disorder early early warning warning Implantable Implantable symptoms symptoms Cardioverter Cardioverter of of hypoglycaemia? hypoglycaemia? 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PrescriptionPrescription drugs drugs Systolic:DoesSystolic:Does your your ______patient patient have have diabetes diabetes controlled controlled Diastolic: Diastolic: by by medication? ______medication?______ChronicChronicAlcoholIfAlcoholIf DateYes, Yes, Depression Depression pleaseof please last episode:complete complete ______the the following. following.Tourette’sTourette’s Syndrome Syndrome If yes,Other: complete ______the following. ‘severe‘severe hearing hearing loss’. loss’. If If Yes Yes -Refer -is is your your to patient‘Assessing patient compliant compliant Fitness with with to Drive’medication? medication? publication for definition of theirOther:Prescription visual ______drugsfield is worse than the criteria contained If6.If6. 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PSYCHIATRICPersonality PSYCHIATRICPersonalityIllicitPleaseIllicitPlease6.‘severeAny MUSCULOSKELETALdrugs drugs end tick tickhearingDisorder Disorderorgan the theCONDITION CONDITION relevant effects:relevantloss’. please condition(s): condition(s): CONDITION specify:Other:Other: ______mustAlcohol complete the Eyesight Certificate. AnyAny end end organ organ effects: effects: (please (please specify) specify)______IfIf Yes, Yes, please please complete complete the the following. following. Other Other Cardiovascular: Cardiovascular: ______Other:Other:6. MUSCULOSKELETAL ______CONDITION DoesPleaseDoesPlease your your tick tick patient patientthe the relevant relevant have have a a musculoskeletalcondition(s): musculoskeletalcondition(s): condition? condition? PrescriptionPrescription drugs drugs 4.4. DIABETES DIABETESwith any medication taking; Any Illicitend organdrugs effects: (please specify)______ADDITIONAL NOTES: Provide comment to each Yes condition(s) below including reference to the specific condition (e.g. 4. Diabetes). 3.Any3.Any HYPERTENSION HYPERTENSION end end organ organ effects: effects: please please specify: specify: ______DoesDoesPrescription PrescriptionyourDoes yourSevereSevere patient patientyour Arthritis Arthritisdrugspatient drugsrequire require have medication? medication? a musculoskeletalOtherOther Musculoskeletal Musculoskeletal condition? Conditions Conditions No No Yes Yes 8.10.Any PSYCHIATRIC SUBSTANCE end organ effects: MISUSECONDITION (please specify)______If6.If6. 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Systolic:DoesLimb youryour ______patient patient have have a musculoskeletal a neurological Diastolic: / condition? neuromuscular ______condition? Chronic Depression Tourette’s Syndrome 4.4. DIABETES DIABETES 10.10. SUBSTANCE SUBSTANCEIf Yes, please MISUSE MISUSE complete the following. Are glasses or contact lenses required for driving? No Yes 5.Date5.Date HEARING HEARING of Ifof Yes,last last episode: pleaseepisode:LOSS LOSS complete ______the following. DoesDoes yourIsIf your Yes,the patient patientcondition please require require complete likely medication? medication? to theaffect following. driving? No No Yes Yes Personality Disorder Other: ______DoesDoes your your patient patient have have a a musculoskeletal musculoskeletal condition? condition? DoesAny DoesAny Other:end Other: endyour your organ organ ______patient______patient effects: effects: currently currently (please (please misuse misusespecify) specify) alcohol ______alcohol______or or drugs? drugs? Personality Disorder Other: ______DoesDoes your your patient patient have have severediabetes severediabetes hearing hearing controlled controlled loss? loss? by by medication? medication? Please4. DIABETES tick the relevant condition(s): IfAnyIf AnyYes, Yes, end end please please organ organ complete completeeffects: effects: please the pleasethe following. following. specify: specify: ______IfIf Yesyes, Yesyes, -PleaseIf4. complete - iscomplete Yes, isDIABETES your your please tick patient patient the the the following.complete following. compliantrelevant compliant the condition(s): with withfollowing. medication? medication? Date of most recent episode: __ / __ / __ Does your patient require medication? No Yes ReferRefer to to ‘Assessing ‘Assessing Fitness Fitness to to Drive’ Drive’ publication publication for for definition definition of of DoesSevere your Arthritis patient have diabetesOther controlledMusculoskeletal by medication? Conditions Please‘severeIfPlease‘severeIf Yes, Yes, please tickhearingplease tickhearing the the complete complete loss’.relevant loss’.relevant the thecondition(s): condition(s): following. following. 10.10. SUBSTANCEAlcohol SUBSTANCEAlcoholPleaseDoes your tick patientMISUSEthe MISUSE relevant have condition(s):diabetes controlled by medication? If Yes - is your patient compliant with medication? 5.5. HEARING HEARING2. CARDIOVASCULAR LOSS LOSS DISEASE Limb If you are not completing the other sections of this form please provide your details. DiabetesDiabetesSevereSevere controlled Arthritis controlledArthritis by by Insulin InsulinOther Other Musculoskeletal Musculoskeletal Tablet Tablet Conditions Conditions Does9.Does9. SLEEP SLEEPIllicitIllicit your your Limbdrugs drugsDISORDER DISORDERpatient patient currently currently misuse misuse alcohol alcohol or or drugs? drugs? DoesDoes your your patient patient have have severe severe hearing hearing loss? loss? If Yes,Brain please Aneurysm complete the following.MuscularParkinson’s Dystrophy Disease Does your patient have a cardiovascular condition? IfDoesIfDoes yes, yes,PrescriptionPrescription Isyour complete yourcomplete the patient conditionpatient thedrugs thedrugs have following. havefollowing. likely a a sleepto sleep affect disorder? disorder? driving? ReferIsReferIs Limbyour Limbyour toIf topatient Yes,patient‘Assessing ‘Assessing please compliant compliant Fitness completeFitness with with to to medication theDrive’ medicationDrive’ following. publication publication ? ? for for definition definition of of DiabetesCerebral controlled Palsy by Insulin Parkinson’s TabletSeizure Disease 9. SLEEP DISORDER 6.6. MUSCULOSKELETAL MUSCULOSKELETAL CONDITION CONDITION IfIf Yes, Yes,AlcoholAlcohol Diabetesplease please complete complete controlled the the by following. following. Insulin Tablet 9. SLEEP DISORDER Is‘severeDoesIs‘severeDoes the the conditionthe conditionthe hearing hearing patient patient likelyloss’. likelyloss’.experience experience to to affect affect early driving?early driving? warning warning symptoms symptoms of of hypoglycaemia? hypoglycaemia? Date of last episode: __ / __ / __ Does your patient have a sleep disorder? Please tick the relevant condition(s): Any Any end endIs Dementiayourorgan organ patient effects: effects: compliant (please (please specify) withspecify) medication______Seizure______? Does your patient have a sleep disorder? DoesDoes your your patient patient have have a a musculoskeletal musculoskeletal condition? condition? IllicitIllicit drugs drugs If Yes, please complete the following. DoesEpilepsyEpileps*y*** the patient experience earlySpace-occupying warningSpace-occupying symptoms Lesion of hypoglycaemia? (brain Lesion tumour) Medical Practitioner / Optometrist’s Name Date IfIf Yes, Yes, please please complete complete the the following. following. Coronary Artery Bypass Grafting (CABG) Prescription PrescriptionDoes the patientdrugs drugs experience early warning symptoms of hypoglycaemia? Date of last episode: __ / __ / __ (brain tumour) 6.PleaseDate6.PleaseDate MUSCULOSKELETAL MUSCULOSKELETAL of of tick last ticklast theepisode: theepisode: relevant relevant ______condition(s): CONDITIONcondition(s): CONDITION Other:Other:Head ______Injury Stroke Dilated Cardiomyopathy Stroke AnyAnySevereSevere end end organ organArthritis Arthritis effects: effects: please pleaseOther specify:Other specify: Musculoskeletal Musculoskeletal ______Conditions Conditions AnyAny end endDate HeadMultipleorgan organ of last Injuryeffects: effects: Sclerosis episode: (please (please ______specify) specify)______Subarachnoid______Haemorrhage DoesDoes your your Cardiac patient patient Aneurysmhave have a a musculoskeletal musculoskeletal condition? condition?Heart Failure Date of last episode: ______Date of last episode: __ / __ / __ Other: ______IfIf Yes, Yes, please please complete complete the the following. following. Multiple Sclerosis Medical Practitioner / Optometrist’s Signature Provider Number Contact Number LimbLimb 10.10. SUBSTANCE SUBSTANCEAny end organ MISUSE MISUSE effects: please specify: ______Subarachnoid Haemorrhage 5.5. HEARING HEARING Cardiac LOSS LOSS Arrest Heart Transplant PleasePlease tick tick the the relevant relevant condition(s): condition(s): DoesDoes your yourMuscular patient patient Dystrophy currently currently misuse misuse alcohol alcohol or or drugs? drugs? IsIs the the condition condition likely likely to to affect affect driving? driving? *Date of last episode: __ / __ / __ Date of last episode: __ / __ / __ 10. SUBSTANCE MISUSE DoesDoes your yourCardiac patient patient Pacemaker have have severe severe hearing hearing loss? loss?Hypertrophic Cardiomyopathy IfIf yes, yes, complete complete the the following. following. 10. SUBSTANCE MISUSE SevereSevere Arthritis Arthritis OtherOther Musculoskeletal Musculoskeletal Conditions Conditions 5. HEARING LOSS ReferRefer to to ‘Assessing ‘Assessing Fitness Fitness to to Drive’ Drive’ publication publication for for definition definition of of Other (please specify) Does your patient currently misuse alcohol or drugs? Congenital Heart Disorder Implantable Cardioverter Defibrillator AlcoholAlcoholDoes your patient have severe hearing loss? ‘severe‘severeLimbLimb hearing hearing loss’. loss’. Does your patient have severe hearing loss? If yes, complete the following. IllicitIllicitRefer drugs drugs to ‘Assessing Fitness to Drive’ publication for definition of ADDITIONAL NOTES: Provide comment to each Yes condition(s) below including reference to the specific condition (e.g. 4. Diabetes). IsIs the the condition condition likely likely to to affect affect driving? driving? Alcohol Other Cardiovascular: ______8.‘severe PSYCHIATRIC hearing loss’. CONDITION PrescriptionPrescription drugs drugs Illicit drugs 3. HYPERTENSION Illicit drugs 6.6. MUSCULOSKELETAL MUSCULOSKELETAL CONDITION CONDITION Prescription drugs Does your patient have blood pressure consistently greater than 200 AnyAny end endIf Yes, organ organ please effects: effects: complete (please (please the specify) specify) following.______DoesDoes your your patient patient have have a a musculoskeletal musculoskeletal condition? condition? 6. MUSCULOSKELETAL CONDITION IfIf Yes, Yes, systolicplease please complete completeor greater the the than following. following. 110 diastolic (treated or untreated)? PleaseDoes your tick patient the relevant have a musculoskeletalcondition(s): condition? Any end organ effects: (please specify)______PleasePlease tick tick the the relevant relevant condition(s): condition(s): Does your patient have a musculoskeletal condition? If Yes,Anxiety please complete the following. Post Traumatic Stress Disorder (PTSD) SevereSevereBlood Arthritis Arthritis pressure readings:OtherOther Musculoskeletal Musculoskeletal Conditions Conditions PleaseBipolar tick Affective the relevant Disorder condition(s):Schizophrenia LimbLimbSystolic: ______Diastolic: ______ChronicSevere DepressionArthritis Other MusculoskeletalTourette’s Syndrome Conditions IsIs the the condition condition likely likely to to affect affect driving? driving? Personality Disorder Other: ______Limb 4. DIABETES DoesIs the yourcondition patient likely require to affect medication? driving? No Yes Does your patient have diabetes controlled by medication? If Yes - is your patient compliant with medication?
If Yes, please complete the following. Diabetes controlled by Insulin Tablet 9. SLEEP DISORDER Is your patient compliant with medication ? Does your patient have a sleep disorder? If Yes, please complete the following. Does the patient experience early warning symptoms of hypoglycaemia?
Date of last episode: ______Other: ______Any end organ effects: please specify: ______
10. SUBSTANCE MISUSE 5. HEARING LOSS Does your patient currently misuse alcohol or drugs? Does your patient have severe hearing loss? If yes, complete the following. Refer to ‘Assessing Fitness to Drive’ publication for definition of ‘severe hearing loss’. Alcohol Illicit drugs Prescription drugs 6. MUSCULOSKELETAL CONDITION Does your patient have a musculoskeletal condition? Any end organ effects: (please specify)______If Yes, please complete the following. Please tick the relevant condition(s): Severe Arthritis Other Musculoskeletal Conditions Limb Is the condition likely to affect driving? or Service SA Centre, or mailed to PO Box 1, Walkerville SA 5081 Telephone Enquiries: 13 10 84 Additional Comments www.dtwww.sa.gov.auei.sa.gov.au - ABN - ABN 92 36692 3 28866 288 135 135 MR 713 www.dtei.sa.gov.au - ABN 92 3FOLD 66 288MayMay 135 bebe lodglodgeded at at any any RServiceegistration SA Centre,and Licen or smaileding Centr toe 08/06
SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD May be lodged at any Registration andorGPO L Seicenr viceBoxsing SA 1533,Centr Centre, eAdelaide or mailed SA 5001to PO Box 1, Walkerville SA 5081 (see also MR215A) ...... or Service SA Centre, or mailed to POCERTIFIC Box 1, Walkerville SA 5081 ATE OF FITNESS - Under section 148 of the Motor Vehicles Act 1959 you have a legal obligation to inform the Registrar of Motor Vehicles if CERTIFICATEwww.dtTewww.sa.gov.auTelelep phonhoenei.sa.gov.aue Enqui Enquiries: -rie ABN s:- ABN1 133 92 10 10 36692 84 84 OF3 28866 288 135 FIT 135 NESS MR 713 you have reasonable cause to believe Additionalthat your Comments patient is suffering from a physical or mental illness, disabilityTe orle phone Enquiries: 13 10 84 Government (see also MR215A) www.dtei.sa.gov.au - ABN 92 3FOLD 66 288 135 MR 713 LMPR08/06 Additional Comments ...... MayMay bebe lodglodgeded at at any any RServiceegistration SA Centre,and Licen or smaileding Centr toe of South Australia
SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD deficiency that is likely to endanger the public if your patient drives a motor vehicle. May be lodged at any Registration andHEAVorGPO L Seicenr viceBoxsing SA 1533,Centr Centre, eYAdelaide oVEHICLEr mailed SA 5001 to PO Box 1, Walkervi DlleRIVER SA 5081 08/06S (see also MR215A) ...... LIGCERTIFICHT VEHICLAETE (PRIVATE) OF FITNE DRIVER(see alsoSS MR215A) -S Department of Planning, Under section 148 of the Motor Vehicles...... Act 1959 you have a legal obligation to inform the Registrar of Motor orVehicles Service SA if Centre, or mailed to PO Box 1, Walkerville SA 5081 If you consider...... it prudent you may recommend that your patient undertakes a practical driving assessment. This is irrespectiveCERTIFIC of your ATECERTIFICATETeTelele p pOFhonhonee Enqui Enquiries: FITNEries: 1 133 10 10 84 84OFSS FIT - NESS Transport and Infrastructure you have reasonable cause to believe Additionalthat your Comments patient is suffering from a physical or mental illness, disabilityTe orle phone Enquiries: 13 10 84 LMPR Government (see also MR215A) patient’sAdditional age or Commentsdriver’s licence class...... MR 713 deficiency that is likely to endanger the...... public if your patient drives a motor vehicle. LICENCEHEAVY CLASSES VEHICLE C, RDATE, DRIVER LMPRR,08/06 LRS of South Australia HEAVY VEHICLELIGHT VEHICDRIVERLE (PRIVATE)S DRIVER(see also MR215A) S ...... CERTIFICATE OF FITNESS - Department of Planning, ...... If you consider...... it prudent you may recommend that your patient undertakes a practical driving assessment. This is irrespectiveCERTIFIC of your ATE OF FITNESS - CLIENT No. (This is your Driver’s Licence Number) Transport and Infrastructure patient’s age or driver’s licence class...... HEAVY VEHICLELICENCEHEAV DY RIVERCLASSES VEHICLES C, RDATE, DRIVER LMPRR, LRS
...... Driver’s Licence No: If you consider that your patient may be unfit...... to drive, please immediately return the completed certificate to CLIENT No. (This is your Driver’s Licence Number) ...... CLIENT No. (This is your Driver’s Licence Number) Locked Bag 700, Adelaide SA 5001. Information may be immediately faxed to 8402 1977...... WHO NEEDS TO COMPLETE THIS FORM? CLIENTWHAT No. YOU (ThisDriver’s W isILL your NEED Driver’s Licence TO DLicenceO Number)No: IfIt youis recommended consider that thatyour you patient keep may a copy be unfitof...... this to form drive, for please your immediatelyown records. return the completed certificate to Class of Licence: ...... CLIENT No. (This is your Driver’s LicenceTO O Number)BTAIN/RETAIN YOUR DRIVER’S LICENCE, YOU ARE Locked Bag...... 700, Adelaide SA 5001. Information may be immediately faxed to 8402 1977. Any person who drives a motor vehicle with a GVM exceeding ...... REQUIRED TO: ...... 8000kg and- MEDICAL...... PRACTITIONER’S DECLARATION WHO NEEDS TO COMPLETE THIS FORM? 1. Make an appoinWHATtme ntYOU with WILL you NEEDr reg ulTOar D trOeating doctor for a long It is recommended that you keep a copy of...... this form for your own records. Class of Licence: ...... WHO NEEDS TO COMPLETE THIS FORM? WHAT YOU WILL NEED TO DO (45minute) consultation. The cost of this consultation is// your ...... • Is aged 70 years or more TToO O obtain/retainBTAIN/RETAIN YOUyourR DDdriver’sRIDueVER’S’S licence,LICDate:ENCE, youYOU areAREARE required to: ...... Any person who drives aT Omoto OBTAIN/REr vehiclTAIe Nwith YOU aR GDRIVMVER ’Sex LICceeENdiCE,ng YOU AREQU REr esIpoREDns TO:ibility...... Any person who drives a motor vehicle with a GVM exceeding Make an appointment with your regular treating doctor for a long On I examined...... 8000kg and- REQUIRED TO: 2. Explain to your doctor the reason for the consultation. MEDICAL...... PRACTITIONER’S DECLARATION...... • Has a medicalWHO NEEDS condition TO COMP or LETdisabilityE THIS FOwhichRM? may affect (45 minute) consultation.WHAT YOU When WILL NEED making TO theDO appointment: (Date of Examination)...... (Patient’s name) 8000kg and- 1.3. MaCompke anlete app Secointionstme 1nt and with 2 ofyou thir sreg foulrmar be trforeeatin hgandi docntorg itfor to a yo longur ...... WHO NEEDS TO COMPLETE THIS FORM?or theirService ability SA to Centre, drive. or1. mailed Make an to app POoinWHAT Boxtme ntYOU 1 ,with Walkervi WILL you NEEDr reglle ulTO arSA D trO e5081ating doctor for a long // ...... TTo1.O( dOExplain 45obtain/retainoctor.BTmiAIN/REnu B te)theeTAI s ureconsulreasonN YOU yourto tatisign Rfor Ddriver’son.RI Due theSVEect T Rconsultation.’Sheion licence,LICDate: cos 2EN tin CofE, t hethyouYOUis p rcon areAREesen surequired cltatie ofon you isto: ry docour tor...... • AIsny aged pe rs70on years who ordrive mors ea moto(45mir vehiclnute) econsul with tatia Gon.VM T heex ceecosdit ofng this consultation is your ...... • Is aged 70 years or more www.dtTelephonei.sa.gov.aue Enquirie s:- ABN13TO 10 O BT92 84AIN/RE 366TAI 288N YOU 135R DRIVER’S LICENCE, YOU A REQU2.RE r CompleteesIpoREDns TO:ibil itysections. 1 and 2 of this form before handing it to your On I examinedAdditional Comments Any person who drives a motor vehicle withwww.sa.gov.au• Thea G VMlicence exce clasedin ses- ABNg that includ 92res 366poe tnshese ibil288 ityvehicle 135. s 4.Make Take an s peappointmentctacles, heari withng aid yours, the regular nam estreating of any doctormediMRc atiofor nsa 713long you
...... www.dtei.sa.gov.au - ABN 92 3FOLD 66 288 135 REQUIRED TO: 2. Explain to your doctor the reason for the consultation...... May • 8Has00 be0kg a medicallodg and-ed atcondition any R eorgistration disability andwhich L icenmay saffecting Centr e 2. mayEdoctor.xpl aiben cuBetorr ysureenoutlyr tod taoc signkitorng, Sectionthe et c.rea toson 2the in fo ctheron the supresence ltaticonsonultation. of your.08/06 doctor...... May be lodged at any Service SA Centre, or mailed to (45 minute) consultation. When making the appointment: SECTION...... 5: MEDICAL PRACTITIONER’S DECLARATION FOLD 2. Explain to your doctor the reason for the cons1. Maultatike onan. appointment with your regular treating doctor for a long This patient...... has been treated at this clinic for years months. May • 800Has be0k a glmedicalodg ande-d atcondition any R eorgistration disabilityWhat andwhich L toareicenmay MR;do saffecting withHR; Centr HC thee and completed MC. certificate 3. Complete Sections 1 and 2 of this form before handi(seen alsog it MR215A)to your (Date of Examination) (Patient’s name) orGPO theirSer viceBox ability SA 1533, to Centre, drive. Adelaide or1. mailed Ma SAke an 5001 to app POoin Boxtment 1 ,with Walkervi your reglleul arSA tr e50813.ati Takeng d octorspectacles, for a lonhearingg aids, the names of any medications you ...... CERTIFIC3. CompAleteTE Sections 1 OFand 2 of thi sFITNE form befo 1.r (deExplain45 octor.hamindinu ngB thete)e itSSs ureconsulreasonto yo tour tatisign for-on. theSect T consultation.heion cos 2 tin of t heth isp rconesensucltatie ofon you isr y docourt or. Under section 148 of the Motor Vehicles...... Act 1959 you have a legal obligation to inform the Registrar of Motor orVehicles theirService ability SA if to Centre, drive. or mailed to PO B• oxIs aged1, Wa 70lke yearsrvi orlle morSA e 508(451minute) consultation. The cost of this consul maytati beon currently is your taking, etc. to the consultation...... • Is aged 70 years or more CERTIFICATEorTeTele leSep prhonhovicenee SAEnqui Enquiries:IMPORTANT Centre,ries: 1o 13r3 mailedINFORMATION10d 10octor. 84 84OF Btoe POsure FIT TOBoxto signAPPLICANTS! 1, SNESWalkerviection 2 inOnlylleS the SA in pr exceptionalesenc 4.50812. rTaCompleteespoeke o nssfpe youibilc tacases ityrsectionscles, do. ct wouldheor ari.1 andng a aid person2 s,of thethis nwho formames has beforeof any handingmedicatio it nsto yoyouru you have...... reasonable cause to believe Additionalthat your Comments patient is suffering from a physical or mental illness, disabilityTe orle phone Enquiries: 13 10 84 • The licence classes that includ respoe tnsheseibil ityvehicle. s LMPR (see also MR215A) ...... • ReturnTe• Haslep honto a medical GPOe Enqui Box conditionrie 1533,s: 134. or 10AdelaideTa disability ke84 specta whichcles,5001 he may orari ng any affect aid Services, the nam SAes of Customer 2. any mayEdoctor. xpmel aibedinMRc cuatiBe tServiceorr ons ysureenou 713 tlyyour tod taoc Centresignkitorng, Sectionthe et c.rea toson 2the in fo ctheron the supresence ltaticonsonultation. of your. doctor. Additional Comments ...... • The licence classes that include these vehiclewww.dtwww.sa.gov.auepilepsys ei.sa.gov.au or diabetes - ABN - controlled ABN2. 92 Exp 36692lai 3nby 288 6t o6oral y288ou 135 medicationr d 1oc35tor the orrea insulinson for tbehe consideredconsultation for. a licence to drive a heavy vehicle. If youMR 713 deficiencyThisIn my patient opinion...... thathas the been is person likely treated whoto endangerat is thisthe clinicsubject the Additionalfor...... of public this Comments report: if your patient years drives a motor months. vehicle. • Has a medical condition or disabilityWhat whichHEAV toaremay MR;do affect withHR; HC theY and completed VEHICLEMC may. be curr encertificatetly taking, etc. t o Dthe conRIVERsultati3. onConot.mp responsiblelete08/06 SectiSons for 1the and cost 2 ofof thithes foconsultation.rm before handing it to your FOLD www.dtei.sa.gov.au - ABN 92 3FOLD 66 288 135 3. Take spectacles, hearing aids, the names of any medications you ...... LIGMayMay their H bebe ability lodglodgedThave e toVEHICd at drive.eitherat any any of RService3. thesee gistrationCompL conditions SAleEte S Centre,andec(PRIVATE)tions itL mayicen 1 orand sbemaileding 2 preferableof Centr thi sto foerm to befo have DRIVERre hayourn(seedi ngtreating also it MR215A)to yo specialistur S physician conduct 08/06 ...... are MR; HR; HC and MC. doctor. Be sure to sign Section 2 in the presence of your doctor. FOLD SECTION 5: MEDICAL PRACTITIONER’S DECLARATION FOLD CERTIFICATE OF FITNESS - ...... May their be ability lodge tod atdrive. any Registration• andEnquiries: Licensing 13 Centr 10 84e (see also MR215A) ...... CERTIFICATEor Se OFrvice SA Centre,FITNE or maileddoctor. Btoe POSSsure Boxto sign - 1, SWalkerviection 2 inlle the SA pr esenc5081 maye o bef you currentlyr doctor taking,. etc. to the consultation. If you consider...... it prudent you may recommend...... that your patient undertakes a practical driving assessment. This is irrespective of your GPO BoxIMPO 1533,IMPORTANTRTAN AdelaideT IN FOINFORMATION RMSA AT5001IOtheN examination TO TO APPLICANTS! APPLIC inAN order OnlyTS! to Only in avoid exceptional4. inTa twoexceptionalke s consultations.pec tacasescles, cases wouldheari wouldng a aid person s,a theperson nwhoam whoes has of hasany amedi cardiaccatio ns you ...... or Service SA Centre, or mailed to POCERTIFIC B• oxThe 1 ,licence Walke clasrviseslle that SA includ5081e AtheseTE vehicles OF FITNESS - Under section 148 of the Motor Vehicles...... Act 1959 you have a legal obligation to inform the Registrar of Motor Vehicles ifIMPORTANT INFORMATION• CERTIFICATEReturn TeTOTelele APPLICANTS!p p hontoho neGPOe Enqui Enquiries: Box Onlyrie 1533,s: in 1 exceptional1334. 10AdelaideTa 10 ke84 84 OFspec tacases cles,5001 FIT wouldhe orari ng any NESa aid person Services, the nwhoamS SAes has of Customer anymay me bedic cuati Servicerronsen tlyyou ta Centreking, etc. to the consultation. patient’sMeets the age relevant or driver’s medical licence standard class...... Yes No • The licence classes that include these vehicleepilepsys condition, or diabetes epilepsy controlled or diabetes by controlled oral medication by oral ormedication insulin be or considered insulin beLMPR forconsidered a licence for to drivea licence a heavy to drive vehicle. a heavy If you vehicle. In my opinion the person who is the subjectAdditional...... of this Comments report: Telephone Enquiries: 13 10 84 LICENCEHEAVSECTION are MR; 1: HR; - YOUR HCY andDETAILS.CLASSES VEHICLEMC may. Please be curr enwritetly ta clearlyki ng,C, et c. using RDATE,t o Dthe BLOCK conRIVERsultati LETTERS onnot. responsible R, LRS for the cost of the consultation. (see also MR215A) you have...... reasonable cause to believe that...... your patient is suffering from a physical or mental illness, disability orepilepsy or diabetes controlled by oral medication or insulin be considered for a licence to drive a heavy vehicle. If youMR 713 LMPR Government If no, pleaseAdditional...... provide Comments details below: ...... HEAV are MR; HR; HCY and VEHICLEMC. If you havehave Dany either ofRIVER these of these conditions conditions it mayS it maybe preferable be preferable to have to haveyour treatingyour treating specialist specialist physician physician conduct conduct the examination in deficiency that is likely to endanger the public if your patient drives a motor vehicle. have either of these conditions• Enquiries:HEAV it may be 13 preferable 10 84Y to haveVEHICLE your treating specialist(to be physician completed D RIVERconduct in BLOCK08/06S letters prior to seeing your doctor) of South Australia ...... SECTION 1: YOUR DETAILS CLIENT No. (This is your Driver’s Licence Number) ...... LIGHIMTPO VEHICIMPORTANTRTANT IN FOINFORMATIONRMLATEIOthe (PRIVATE)N examination TOTO APPLICANTS! AorderPPLIC intoAN orderavoid OnlyTS! to twoOnly in avoid exceptionalconsultations. DRIVERin twoexceptional(see consultations. also cases MR215A) cases would wouldS a person a person who who has has a cardiac ...... CERTIFICATE OF FITNESS - Department of Planning, Please...... answer the following questions Yes / No IMPORTANT INFORMATIONthe examination TOSURNAME APPLICANTS! in order Only to in avoid exceptional two consultations. cases would a person who has If Meetsyou consider the...... relevant it prudent medical you standard may recommend that your patient undertakesYes a practical driving No assessment. This is irrespectiveCERTIFIC of your ATEepilepsy condition,OF or diabetes epilepsyFITNE controlled or diabetes by controlled oralSS medication by- oral ormedication insulin be or considered insulin be forconsidered a licence for to adrive licence a heavy to drive vehicle. a heavy If you vehicle. Transport and Infrastructure ...... SECTION 1: - YOUR DETAILS. Please write clearly using BLOCK LETTERS ...... epilepsy or diabetes controlled by oral medication or insulin be considered for a licence to drive a heavy vehicle. If you patient’sIf no, please age...... or provide driver’s details licence below: class. In...... accordance with the National Transport Commission standards “Assessing Fitness to Drive”- SECTION 1: - YOUR DETAILS. PleaseSurname write clearlyIf you have usinghave any either BLOCK of these of theseLETTERS conditions conditions it may it maybe preferable be preferable to have to yourhave treatingyour treating specialist specialist physician physician conduct conduct the examination in ...... have either of these conditionsSECTIONLICENCEHEAV it GIVENmay beNAMES1: preferable YOURY CLASSESto haveVEHICLE DETAILS your treating specialist(to C, be physician completedRDATE, D RIVERconduct in BLOCK LMPRR, LRS letters prior to seeing your doctor) ...... CLIENT No. (ThisDriver’s is your Driver’s Licence Licence Number)No: If you consider that your patient may be unfitDo...... you to cnsider drive, the applicant please medically immediately and psychologically return fit to drive the a heavycompleted commercial vehicle?certificate to HEAVY VEHICLE DRIVERthe examinationS order into orderavoid totwo avoid consultations. two consultations...... Please answer the following questions Yes / No Giventhe examination namesSURNAME in order to avoid two consultations.CLIENT No. (This is your Driver’s Licence Number) Date of birth MR712 09/20 LockedPatients Bag who...... 700, hold Adelaide a licence SA other 5001. than Information a “car” licence may beare immediately required to faxedundergo to 8402a practical 1977. driving assessment at age 85 and everySURNAME year CLIENT No. (This is your Driver’s Licence Number) PleasePlease answer answer the followingthe following questions questions Yes / No Yes / NoIf ...... ‘No’, do you consider the applicant medically and psychologically fit to drive a light vehicle? SECTION 1: - YOUR DETAILS. Please write clearly using BLOCK LETTERS ...... HOME ADDRESS thereafter...... to retain the additional licence Inclass. accordance with the National Transport Commission standards “Assessing Fitness to Drive”- SECTION 1: - YOUR DETAILS. PleaseSurname write clearly using BLOCK LETTERS In...... accordance with the National Transport Commission standards “Assessing Fitness to Drive”- Home GIVENaddress NAMES In accordance with the National Transport CommissionDo standards you consider “Assessing that it Fitness is prudent to Drive”- or necessary for the applicant to undergo a practical driving assessment? GIVEN NAMESWHO NEEDS TO COMPLETE THIS FORM? WHAT YOUDAYTIME WILL NEED TO DO It is recommended that you keep a copy ofDo...... thisyou cnsider form the forapplicant your medically own and records. psychologically fit to drive a heavy commercial vehicle? GIVEN NAMES Class of Licence: Please...... answer the following questions Yes / No ______Given namesSURNAMESUBURB/TOWN POSTCODETO OBTAIN/RETAIN YOUR DPHONERIVER’S No. LICDateENCE, YOUof AREbirth Do...... you cnsider the applicant medically and psychologically...... fit to drive a heavy commercial vehicle? Any person who drives a motor vehicle with a GVM exceeding CLIENT No. (ThisDriver’s is your Driver’s Licence Licence Number)No: If you considerPleasePlease answer answer that the following theyour following patientquestions questions Yes may / No Yesbe /unfit NoIfNOTE ...... ‘No’, : to doA practical youdrive, consider driving please the assessment applicant immediately medically cannot be and undertaken psychologically return if the theapplicant fit to completed drive is considereda light vehicle? to certificate be medically or psychologicallyto unfit to drive.SURNAME Suburb/Town PostcodeREQUIRED TO: Daytime phone no ...... ______HOME ADDRESS CLIENT No. (This is your Driver’s Licence Number) If ‘No’, do you consider the applicant medically and psychologicallyIn...... accordance fit with to drivethe National a light vehicle? Transport Commission standards “Assessing Fitness to Drive”- MEDICALLocked Bag...... PRACTITIONER’S 700, Adelaide SA DECLARATION5001. Information may be immediately faxed to 8402 1977. HOME ADDRESS 8000kg and- InInDo accordance accordance you consider with with the that National the it Nationalis Transportprudent Transport Commission or necessary CommissionDoIf standards...... recommending you for consider the “Assessing applicant standardsthat a practical it Fitness is prudentto driving“Assessing undergoto Drive”- or assessment, necessary a Fitness practical for please the to applicantdrivingDrive”-note in the toassessment? spaceundergo below a practical any particular______driving factors assessment? in relation to this patient that the Driving Assessor should be made Home addressGIVENPOSTAL NAMES WHOADDRESS NEEDS (If di erent TO COMP fromLET above)E THIS FORM? 1. Make an appoinWHATtment YOUwith WILLyour NEED reg ulTOar D trOeating doctor for a long ...... GIVEN NAMES DAYTIME Do...... you consider that it is prudent or necessary for the applicantDo...... you cnsider to undergo the applicant a practical medically driving assessment?and psychologically fit to drive a heavy commercial vehicle? WHO NEEDS TO COMPLETE THISPostal FORM? address if different from aboveWHAT YOU WILL NEED TO DO (45minute) consultation. The cost of this consultation is// your RequiresDo youa practical cnsider the applicant driving medically test and psychologicallyaware...... fit of to (eg.drive limb a heavy mobility, commercial concentration vehicle? span, etc). Yes No ______• SUBURB/TOWNIs agedWHO 70 years NEEDS or TmorO COMPe LETE THIS FORM? DAYTIME POSTCODETToO O obtain/retainBTAIN/RETAINWHAT YOUyourR DYOUdriver’sPHONERIDueVE WR’SILL No. licence,LICDate: NEEDENCE, TO you YOU DO areARE required to: It is recommended...... that you keep a copy of...... this form for your own records. SUBURB/TOWN Suburb/TownARE Any YOU pers CURRENTLY on who drivePOSTCODE BEINGs aTOmoto OTREATEDBTAIN/REr vehicl TAIBYe NwithANY YOU OTHERaR GDPHONERIVMVE RDOCTOR ’Sex No. LICceeENdiCE,ng OR YOU SPECIALIST Postcode ARErespons FOR ibil ityANY. REASON?Class Daytime of Licence: phoneYES no NO NOTE: A practical driving assessment cannotIfNOTE ...... ‘No’, be : undertakendoA practical you consider driving if the the assessment applicant applicant medicallycannot is considered be and undertaken psychologically to if bethe medicallyapplicant fit to drive is consideredora light psychologically ______vehicle? to be medically or psychologically unfit to drive. Any person who drives a motor vehicle withHOME a GVM ADDRESS exceeding TREQUMakeO OBTIRED AIN/REan TO:appointmentTAIN YOUR withDRIVE yourR’S LIC regularENCE, YOU treating ARE doctor for a long On IfNOTE ...... ‘No’,: doA practicalyou consider driving the assessment applicant medically cannotI examined be and undertaken psychologically...... if the applicant fit to drive is considereda light vehicle? to be medically or psychologically unfit to drive. HOME ADDRESS Email• address 8AHas00ny0kg pea medicalrs ao nd-(ifn wh available) conditiono drives aREQU motoor disabilityIREDr vehicl TO: whiche with maya GVM affect exceeding 2. Explain to yourdoctorIn signing the rea thisson form youfort consenthe co tons yourul doctortation releasing. If ...... recommending a practical driving assessment, please note in the space below any particular factors in relation to this patient that the Driving Assessor should be made REQU(45 minute)IRED TO: consultation.to the WhenRegistrar ofmaking Motor Vehicles, the appointment:any medical information that Do...... you consider that it is prudent or necessaryDo...... you for consider the applicant that it is prudentto undergo or necessary a practical for the applicantdriving toassessment? undergo a practical ______driving assessment? 8000kg and- POSTAL ADDRESS (If di erent from above) 1.3.Ma Compke anlete appSecointionstme 1nt andDAYTIMEwith 2 ofyour this reg foulrmar be trforeeatin hgandi docntorg itforto a yolongur (Date ofDoIf Examination) recommending you consider that a practical it is prudent driving or assessment, necessary for please the applicantnote...... in the to spaceundergo below a practical any particular driving factors assessment? in relation to this patient(Patient’s that the Driving name) Assessor should be made POSTAL ADDRESS (If di erent from above)Postal address8their000kg ability and- if to different drive. 1. fromMake anabove appoin tment with your regular treating doctor for a longmay a ect your ability to drive safely. MEDICALRequires...... PRACTITIONER’Sa practical driving DECLARATIONtest aware...... of (eg. limb mobility, concentration span, etc). Yes No SUBURB/TOWN DAYTIME POSTCODE1. (dExplain45ocmitor.nuB thete)e s ureconsulreason to tatisign foron.PHONE theSect T consultation.heion No. cos 2 tin of t heth isprconesensucltatie ofon you isr y docourtor...... • Is agedWHO 70 years NEEDS or TmorO COMPe LETE THIS FORM? 1. Make an appoinWHATtment YOU with W ILLyourou NEEDr reg ulTOar D trOeating doctor for a long awareIf...... recommending of (eg. limb mobility, a practical concentration driving span, assessment, etc). please note in the space below any particular factors in relation to this patient SUBURB/TOWNWHO NEEDS TO COMPLETE THIS FORM?ARE YOU CURRENTLYPOSTCODE BEING( TREATED45minute) BY consul ANY tatiOTHERon.PHONE T DOCTORhe No. cost of OR thi SPECIALISTs consulrespotatins FORonibil is ityANY you. r REASON? YES NO NOTE: A practical driving assessment cannotNOTE...... be : undertakenA practical driving if the assessment applicant cannot is considered be undertaken to if bethe medicallyapplicant is consideredor psychologically to be medically or psychologically unfit to drive.• Is aged 70 years or more WHAT YOU WILL NEED TO DO 4.2. (TaComplete45kemi snupete)cta sections cles,consul hetati ari1 andngon.Due aid 2T hes,of Date:the this cos nt formamof thes isbeforeof conanysu handingmediltationcatio is//it y nstoour yoyour u NOTE: A practical driving assessment cannot be undertaken...... if the applicant is considered to be medically or psychologically unfit to drive. ARE YOU CURRENTLY BEING TREATED BY ANY• SIGNATUREIsThe OTHER agedlicence 70DOCTOR yearsclasses or OR thatmor SPECIALIST include respoe tns heseFORibil ityvehicleANY. REASON?s TToO O obtain/retainBTYESAIN/RE TAI NON YOUyourR InInDdriver’s DATERIsigningsigningVER ’Sthisthis licence,LIC formformEN...... /...... /...... youyouCE, consentconsent youYOU are AREtoto youryour required doctordoctor releasingreleasing to: ...... Email1. Have• address AHasny peayou medicalrso (ifnconsulted wh available) conditiono drives aanyT Omotoor O disabilityBT medicalAIN/REr vehiclTAI whiche Nwithpractitioner YOU mayaR GDRIVM affectVER ’Sex LIC ceewithinENdiCE,ng YOU the A2. RE last mayE doctor.xpl ai12ben cuBetmonthsorr ysureentlyourd totaoctor sign kithatng, Section the e thet c.rea toson medical 2the in fo cthertonhe supresence ltaticopractitionernsonultation. of your. doctor. completing this form does that the Driving Assessor should be made awareIf ...... recommending of (eg. limb a practical mobility, driving concentration assessment, please span, note etc). in the space below any particular factors in relation to this patient that the Driving Assessor should be made In signing this form you consent to REQU yourres doctorIpoREDns releasingTO:ibility. to the Registrar of Motor Vehicles, any medical information that ...... • AHasny pea medicalrson who condition drives a motoor disabilityr vehic lewhich withPOSTAL maya GVM affect ADDRESS exceedin (If di erentg 2. fromExp above)lain to yourdoctor the reason forthe cons3.Make Coultatimp anonle appointmentte. Sections 1 withand 2your of thi regulars form treating before doctor handin forg it at olong your ThisOn patientIf recommending has been a practical treated driving at assessment, thisI examined clinic please notefor...... in the space below any particular years factors in relation to this patient months. that the Driving Assessor should be made POSTAL ADDRESS (If di erent from above) What toare MR;do withHR; HC the and completed MCREQU. IRED TO: certificateto the Registrar of Motor Vehicles,2. 3.any ETake medicalxplai spectacles,n information to you rdrthat dhearingoctoroc tormay t a ect heaids, rea your theson ability namesfo tortr drivethe of safely.co anynsul medicationstation. you aware...... of (eg. limb mobility, concentration span, etc). not• 8Hastheir00 know0kg aability medical and- about? to drive.condition Please3. or Co providedisabilitymplete Sthe whichecti nameons may 1 andof affect medical 2 of this practitioner form befo(45red ochaorminute)tor.n treatingdingBe it consultation.s ureto specialist yo tour sign S Whenection making2 in the thepresen appointment:ce of your doctor. Do...... you recommend conditions be placed on ...... the applicants driver’s licence? ______8000kg and- may a ect your ability to drive safely.1.3. MaCo mpke anlete app Secointionstme 1nt and with 2 ofyourou thir s reg foulrmar be trforeeatin h gandi docntorg itfor to a yo longur (Date ofaware IfExamination) recommending of (eg. limb mobility, a practical concentration driving span, assessment, etc)...... please note in the space below any particular factors(Patient’s in relation name) to this patient their ability to drive. ARE YOU CURRENTLY BEINGd TREATEDoctor. Be BYsure ANY to signOTHER Sect DOCTORion 2 in ORthe SPECIALIST presenc maye o be fFOR you currently rANY doct REASON?or taking,. etc. to the consultation.YES NO ...... their ability toIMPORTANT drive. 1. INFORMATION Make an appoin TOtme APPLICANTS!nt with yourour regOnlyular in tr exceptionale4.atiTangke d octorspec tacases focles,r a lonwouldhearig ng a aid persons, the nwhoames hasof any medications you ...... • SIGNATUREThe licence classes that include these vehicles 1. (dExplain45ococtor.YESmitor. nu B thete) e NOs ureconsulreason to tatisign foron. theSect T consultation.heion cos 2 tin of t heth isp rconesensucltatie ofon you isr y docourt or. If yes, please note your recommendations in...... the space below. ARE YOU CURRENTLY BEING TREATED1. BY ANYHave• SIGNATURE IsOTHER aged you 70DOCTOR consultedyears or OR mor SPECIALIST eany 4. (Ta45 medicalkemi sFORnupete)cta ANY cles,consul practitioner REASON?hetatiaringon. aid Thes, the within cos nt amof thies the sof consul any last metati 12dionc atimonths isons you your thatIn DATEsigning the this formmedical...... /...... /...... /...... /...... you consent practitioner to your doctor releasing completing this form does that...... the Driving Assessor should be made aware of (eg. limb mobility, concentration span, etc). • The licence classes that include these• vehicleReturnepilepsys to GPO or diabetes Box 1533, controlled Adelaide by oral 5001 medication or any orService insulin SAbe consideredCustomer rmayespo bens ibil cufor Servicerrity aently .licenceta Centreki ng,to driveetc. to a theavyhe con suvehicle.ltation . If you Should a licence be issued subject to conditions?...... Yes No • SIGNATUREIs aged 70 years or more In DATEsigning this form...... /...... /...... you consent to4.2. your TaComplete doctorke spe releasingcta sectionscles, he ari1 toandng the aid Registrar 2 s,of thethis of Motorn formam Vehicles,es beforeof any any medical handingmedi informationcatio it nsto yothatyouru In my opinion the person who is the subject...... of this report: • areThe MR; licence HR; clas HCses andthat MCinclud rmayes. poe betnshese ibilcu rrityvehicleently. tas kitong, the eRegistrartc. to ofthe Motor con Vehicles,sultati2. any onEnot medicalxp. lresponsibleai ninformation to you rdrthat dforoctoroc thetormay tcosta ecthe rea yourof sonthe ability foconsultation. tortr drivethe safely.consultation...... are MR; HR; HC and MC. not• Has know a medicalhave about? conditioneither Please of these or providedisability conditions the which name it maymay of beaffect medical preferable practitioner to have maydoctor. oryour treatingbe treating cuBerr sureentlyen tlyspecialist to specialist ta signking, Section et c.physician to 2the in ctheon conduct supresenceltation. of your doctor. If yes, pleaseDo...... you providerecommend details conditions below: be placed on ...... the...... applicants driver’s licence? ______• Has a medical condition or disability• whichEnquiries: may affect 13 10 84 2. Explain to yourdr doctoroctormay ta ecthe rea yourson ability fo tortr drivethe safely.cons3. Co ultatimponlete. Sections 1 and 2 of this form before h anding it to your This patient...... has been treated at this clinic for...... years months. What toare MR;do withHR; HC the and completed MC. certificate 3. Take spectacles, hearing aids, the names of any medications you ...... 2. Please their abilityIM listPO all toIMPORTANTRT drive.theAN Tmedications IN3. FOINFORMATION Co RMmpleATte thatIOtheSecN tiexamination ons TO TOyou APPLICANTS!1 A andtakePPLIC 2 of in(prescribed ANthi orders OnlyTS!form to Only in befoavoid exceptional orrined ococtor. twohaexceptionalotherwise).tor.ndi consultations. ngB e casesit s ureto casesyo twouldo ur Attachsign would Saect personlist iona personif 2necessary whoin t hewho has pr esenhas ac ecardiac of you r doctor. If...... yes, please note your recommendations in...... the space below. IMPORTANT INFORMATION TOSIGNATURE APPLICANTS! Only in exceptional cases would a person who has DATE ...... /...... /...... their ability to drive. may be currently taking, etc. to the consultation. Meets the...... relevant medical standard No Yes SIGNATURE epilepsycondition, or diabetesIMPORTANT epilepsy controlled or diabetesINFORMATIONdococtor.tor. by Bcontrolled eoral sure medication TOto signAPPLICANTS!by DATEoral Sect ormedicationion insulin 2...... /...... /...... inOnly t hebe in or prconsidered exceptional esenc4.insulin Taeke o befs peyou forconsideredc tacasesr acles, do licencect wouldheorari. for ngto a adriveaid person licences, the a heavy nwhotoam drivees hasvehicle. of aany heavy medi If you vehicle.cations you Should a...... licence be issued subject to conditions?...... Yes No SECTION 1: - YOUR DETAILS. Please write clearly using BLOCK LETTERS ...... epilepsy or diabetes controlled by oral medication• The licence or insulin classes bethat considered includ4. Takee t shesepe forcta vehicle acles, licence hes ari ngto driveaids, the a heavy names vehicle. of any me If diyoucations you If no, please...... provide details below: ...... • The licence classes that include these• vehicleReturnepilepsys If youto GPO have orhave diabetes anyBox either of 1533, these controlled of these conditionsAdelaide conditions by oral it5001 maymedication it may orbe preferableany be preferableorService insulin to have SAbe to consideredCustomeryourhave may treatingyour be treating cufor Service rrspecialist aentlyen licencetly specialist ta Centreki physician ng,to driveet c.physician to a conduct theavyhe con conduct suvehicle. theltati examinationon . If you in If yes, please provide details below: ...... IMPORTANT NOTES FOR THE MEDICAL PRACTITIONER In my opinion...... the person who is the subject...... of this report: have either of these conditionsSECTION it aremay MR; be1: preferableHR; YOUR HC and to haveMC DETAILSmay. your be treatingcurrentlyently specialist ta(toking, be et c.physician completed to the con conductsultati onnotin. responsibleBLOCK forletters the cost priorof the consultation. to seeing your doctor) ...... are MR; HR; HC and MC. 2. Please list have all theeither medications of these conditions thatthe examination youit may takeorder be preferable in(prescribedto orderavoid totwo to avoid have consultations. or twoyourotherwise). consultations. treating specialist Attach list physician if necessary conduct Requires a practical driving test Please...... answer the following questions Yes / No No Yes •the Enquiries: examinationSeSectioncSURNAMEtion 80 80 13 o f ofin t10he theorder Motor84 Motor to Vavoidehic Vehiclesles two Act consultations. 1Act959 1959 requires requires certain certain applica applicantsnts for a driver for ’sa licendriver’sce t olicence provide to medi providecal evid medicalence o fevidence the ir of t theirness ...... IMPORTANT INFORMATIONthe examination TO APPLICANTS! in order Only to in avoid exceptional two consultations. cases would a person who has ...... SECTIONto drive.IM 1:PO - YOURRTAN DETAILS.T INFORM PleaseATIO writeN TO clearly A PPLIC usingAN TS!BLOCK Only LETTERS in exceptional cases would a person who has a cardiac ...... In...... accordance with the National Transport Commission standards “Assessing Fitness to Drive”- SECTION 1: - YOURIMPORTANT DETAILS. INFORMATION PleaseSurname write TO clearlyAPPLICANTS! using Only BLOCK in exceptional LETTERS cases would a person who has Meets the relevant medical standard ...... YesNo Yes No IMPORTANTepilepsycondition, or diabetes epilepsy NOTES controlled or diabetes FOR by controlled THEoral medication MEDICAL by oral ormedication insulin PRACTITIONER be or considered insulin be forconsidered a licence for to adrive licence a heavy to drive vehicle. a heavy If you vehicle...... SECTIONIMPORTANTGIVEN NAMES 1: - YOUR NOTES DETAILS. FOR Please THE write MEDICAL clearly using PRACTITIONER BLOCK LETTERS ...... epilepsy or diabetes controlled by oral medicationYou are req orues insulinted to cbeomp consideredlete the Me fordi cala licence and Ey toesigh drivet Cer a tiheavy c ate vehicle.overleaf afIf teryou referring to the standards contained in the National If no, please...... provide details below: Do you cnsider the applicant medically and psychologically fit to drive a heavy commercial vehicle? IMPORTANT NOTES FOR THE MEDICALIf you havehave anyPRACTITIONER either of these of these conditions conditions it may it maybe preferable be preferable to have to yourhave treatingyour treating specialist specialist physician physician conduct conduct the examination in Do you recommend conditions be placed on the licence? No Yes Given3. SeTransHave namescSURNAMEtionpor you80t Commission of tbeenhe Motor the pu V ehicdriverbliclaestion A ofct ” 1 a959 vehicle requires involved certain app inlica ants ”crash w forhi cha driver inis avai the’sla licen blelast fromce 5 t oyears? Austproviroade dsmedi onYesDate cal(02) e vid9 26ofence4 7088birth ofNo thore at ir tness Please...... answer the following questions Yes / No have either of these conditionsSECTIONSection it may be801: preferable of theYOUR Motor to have VehiclesDETAILS your treatingActAssessin 1959 specialistg(to requires Fitness be physician tcertainocompleted Drive applicants conduct in for BLOCK a driver’s letterslicence to prior provide to medical seeing evidence your of theirdoctor) PleasePlease answer answer the followingthe following questions questions Yes / No Yes /D NoEC...... LARATION SecSURNAMEtion 80 of the Motor Vehicles Act 1959 reqNationaluires certa Transportin applica ntsCommission for a driver’s publication licenthece examination to p rovi“Assessingorderde me intodi orderavoidcal Fitness evi totwod enavoid toceconsultations. Drive”o ftwo the consultations. whichir tness is available from Austroads on (02) 9264 7088 ...... If ‘No’, do you consider the applicant medically and psychologically fit to drive a light vehicle? the examinationtowww HOMESURNAMEdrive.aus. ADDRESStroad ins. ordercom.au to. avoid two consultations...... PleaseIn accordance answer thewith following the National questions Transport Yes / Commission No standards “Assessing Fitness to Drive”- to drive. IMPORTANTorIf Yes,at www.austroads.com.au. please provide NOTES details FOR THE MEDICAL PRACTITIONER InIn accordance accordance with with the National the National Transport Transport Commission CommissionDo standards...... N youAME consider OF “Assessing MEDIC standardsthatAL it Fitness is prudent “Assessing to Drive”- or necessary Fitness for the to applicantDrive”- to undergo a practical driving assessment? PROVIDER HomeSECTIONYou addressGIVEN are reqNAMES 1:u es- YOURted to c DETAILS.omplete the Please Medical write and clearlyEyesigh tusing Certi c BLOCKate over LETTERSleaf after referring to the standards contained in the National Please provide...... further details on any of theInDo...... accordance you above cnsider with the questions theapplicant National medically Transport below: and Commissionpsychologically standards fit to drive “Assessing a heavy Fitness commercial to Drive”- vehicle? SECTIONIMPORTANTGIVEN NAMES 1: - YOUR NOTES DETAILS. FOR Please THESurname write UnderMEDICAL clearly sect ionusing 14 PRACTITIONER8 ofBLOCK the Motor LETTERS Vehicles Act you have a legal obligation to inform the RegistrarDAYTIME of Motor Vehicles if you Do...... you cnsider the applicant medically and psychologicallyPRACTITIO fit to driveN aER heavy (Ple ascommerciale Print) vehicle? ______NUMBER You are requested to complete the Me3.dical aTransSehaUnderHavendcSUBURB/TOWNGIVENv tioneEy reasonablepesighor you 80NAMESsectiont Commission otf Cer beentheti c148Motor cause athete of puto overV the ehicdriverbelieveblicle Motoralafestion af A tterofctha ” 1 trefAssessinVehicles a9the59 vehicleerrin areqppligu gto irescAct Fitan tinvolvedhe certness youis st tasufferinan int haveodards appDrive in glia cac fromontlegalantsPOSTCODE ”crash aw forinea hiobligation p chdahy driverin inissi t cavai hetheal ’s orNla licen blemenlasttoat informfromceion tal5 t oalillnessyears? Austp rovi thePHONEroa,de disabi Registrar ds medi No.onYeslit cal(0y 2)or e vid9 ofdef26 enceMotor4icienc 7088 ofyNo thor Vehiclese at ir tif nessyou DDoEC...... youLA cnsiderRATIO the Napplicant medically and psychologically fit to drive a heavy commercial vehicle? SeTransctionpor 80t Commission of the Motor pu Vehicbliclaestion Act ” 1Assessin9Suburb/Town59 reqNationalugires Fit cernessta Transport into appDrivelica ntsCommission” w forhi cha driver is avai’s publicationla licenble fromce to Austp rovi“Assessingroade dsme ondi cal(0 Fitness2) evi 92d64en Postcode to7ce0 88Drive”of torhe at whichir tness is available Daytime from Austroads phone on no (02) 9264 7088 FurtherDECL...... ARA commentsTION on medical condition(s)PleaseNOTEIf ‘No’, answer: doA practical affectingyou the consider following driving the safeassessment questionsapplicant driving medicallycannotYes / No beare and undertaken psychologicallyattached. if the applicant fit to drive is considereda light ______vehicle? to be medically or psychologically unfit to drive. GivenwwwtotIfha names HOMESURNAMEdYes,trive would.aus. ADDRESS pleasetro affecads.ct om hisprovide .auor .her abili detailsty to drive safely. Date of birth If ‘No’, do you consider the applicant medically and psychologically fit to drive a light vehicle? towww HOMESURNAMEdrive.aus. ADDRESStroads.com.au. or at www.austroads.com.au. PleasePleaseDo you answer answer consider the followingthe thatfollowing itquestions is prudent questions Yes / orNo necessaryYes / NoIfDo ‘No’,recommendingN you AMEfor doconsider theOF you MEDIC applicant consider that a practicalAL it isthe prudentto applicantdriving undergo or assessment, necessary medically a practical for andplease the psychologically applicantdrivingnote in the toassessment? spaceundergo fit to below drive a practical anya light particular______vehicle?driving factors assessment? in relation to this patientPROVIDE that theR Driving Assessor should be made HOMEPOSTAL ADDRESS ADDRESS (If di erent from above) In ADaccordanceDRESS with the National Transport Commission standards “Assessing Fitness to Drive”- Postal4. UnderYouIfIs yo addressdriving ua rec seonsi reqctiondu eresaif 14tth significanteddifferent8at ofto the thecomp app Motorleteli cafrom partnt theV isehi Meunofabovecles tdi your cal tActo d a rive nd youoccupation Ey y haouesighve are at legalreqCeru tiores cobligatt aedvoluntaryte tooverion immele toaf informdi af atworkterely ref trethee (e.g.rrinu Rerng gt heto iscouriert trarcheomDAYTIME ofstp anMotorle tedadriverdrds cer Vehicles ctoni orcatetained community ifto y inou t hePO Na Box bus 1,tional driver)? Yes No RequiresDoInNA youaaccordanceME practical consider OF MEDICA that with itdrivingL is the prudent National testor necessary Transport for the applicantCommissionawarePRACTITIO of to(eg. undergo limbN standardsER mobility, ( Plea practicalase Prin “Assessingconcentrationt) driving assessment? Fitness span, etc). to Drive”-No PROVIDEYesR NUMBER YouUnder are se reqctionues t14ed8 ofto thecomp Motorlete theVehi MeclesHomedical Act a ndyou address Ey haesighve at legalCerti cobligatate overionle toaf inform after ref theerrin Regg toist trarheDAYTIME ofst anMotordards V cehiontcalesine ifd y inou t he N ational In accordance with the National Transport CommissionDo standards you consider “Assessing that it Fitness is prudent to Drive”- or necessary for the applicant to undergo a practical driving assessment? haTransWalUndervSUBURB/TOWNGIVENeke reasonableprvor illsectionNAMESt e,Commission 5081 c148ause. of topu the believeblic Motoration tha ” tVehiclesAssessin the applig cAct Fitantness youis sufferin thaveo Drive ga fromlegalPOSTCODE” w a hiobligation pchhy siis cavaial orla blemento informfromtal illness Aust theDAYTIMEPHONEroa, disabi Registrards No.onlit (0y 2)or 9 ofdef26 Motor4icienc 7088y or Vehicles at if you NOTE:PRACTITIONER A practical (Please driving Print) assessment cannotDDoNOTEEC youbeLA : undertakencnsiderARATIO practical the Ndrivingapplicant if the assessment medicallyapplicant cannot and is psychologically considered be undertaken tofit if tobethe drive medicallyNUMapplicant a BERheavy is commercialconsideredor psychologically to vehicle? be medically or psychologically unfit to drive.TranshaSUBURB/TOWNGIVENve reasonablepor NAMESt Commission cause puto believeblication tha ” tAssessin the appliAREgc Fitan YOUtness is sufferin CURRENTLY to Driveg fromPOSTCODE” BEING w ahi pchhy TREATEDissi cavaial orla blemen BY from tANYal illness Aust OTHERPHONEroa, disabili dsDOCTOR No.on ty(0 2)or OR 9 defi2 64SPECIALISTc 7ien088cy or at FOR ANY REASON? YES NOGPO Box FurtherDDoECL youARA cnsidercommentsTIO the Napplicant on medically medical and psychologically condition(s) fit to driveaffecting a heavy commercial safe driving vehicle? are attached. ______DAYTIME wwwtIfha SUBURB/TOWNtyou would.aus answeredtro affecads.ct omhis .auor "Yes", .her abili approximatelyty to drive safely. how many hoursPOSTCODE per day do you drive?PHONE No. Hours: NOTE: A practical driving assessment cannot be undertakenSUBURB/TOW if the applicantN is considered to be medically or psychologically unfit to drive. POSTCODE PHONE No. wwwthat would.austro affecads.ct omhis .auor .her ability to driveSuburb/TownEmail safelIf1533, youaddressy. c onsiAdelaided (ifer th available)at SA the 5001. applicant is t to drive you or the applicant sho Postcodeuld return t he completedIn signing cer ti Daytime cthisa formte in you person consent phone to to your an doctor no releasing y Registration NOTEIf ‘No’,recommendingNADAMEDRES: doA OF practical youS MEDIC consider a drivingpracticalAL the assessment applicantdriving assessment, medicallycannot be and pleaseundertaken psychologically note in if thethe spaceapplicant fit to below drive is consideredanya light particular______vehicle? to befactors medically in relation or psychologically to this patientPROVIDE unfit that to theR drive. Driving Assessor should be made UnderIfan yoHOMEPOSTALd uLi c onsiseensin ADDRESSct ADDRESSiondger Cen 14th8at (Iftof ret di erenthe theor app Service Motorli fromcant SAV above) isehi Centreuncles t t Acto or d rive mayouil y haitou tveo a re a POreqlegal Buoxes obligatt 1,ed Wa toion lkeimmerv toill informdie, at50e81.ly tret heu RernI gntheis eithert rarctoom the of capRegistrar Motorlese,te dit of iscer MotorVehicles reti c ommendedVehicles,cate ifto any y ou medical PO tha informationBoxt you 1, kee thatp a If ‘No’,recommendingNAADMEDRE do OFSS you MEDICA consider a practicalL the applicantdriving assessment, medically andplease psychologically note...... in the space fit to below drive anya light particular vehicle? factors in relation to this patientPROVIDE that theR Driving Assessor should be made If yoHOMEPOSTALu consi ADDRESS ADDRESSder that (If t di erenthe appli fromcant above) is un t4. to driveIs driving you are reqa significantuested to imme partdiat eofly retyoururn toccupationhe completed ceror tvoluntaryi cate to POwork Box 1,(e.g. couriermay a ect yourdriver ability to or drive community safely. bus driver)? Yes No Do you consider that it is prudent or necessaryDoIfaware recommendingPRACTITIO you for of consider the(eg. limbapplicantN ERthat a mobility, practical(Ple it asise prudentPrinto driving concentrationundergot) or assessment, necessary a practicalspan, for please etc). the applicantdrivingnote in the toassessment? spaceundergo below a practical any particular______driving factors assessment? in relation to this patientNUMBE thatR the UnderDriving seAssessorction should 148 of be the made Motor Vehicles ActhaWalc youopvPOSTALekey hareasonablefrvorveill y e,ADDRESSou a 50legalr o81wn c obligat ause(If re. di erentcor tods.ion believe from to inform above) that t thehe a Reppligiscantrart isof sufferin Motor gV ehifromcles a pifhy yousic al or mental illness, disability or deficiency awareIfPRACTITIONER recommending of (eg. limb mobility, (Please a practical Print concentration) driving span, assessment, etc). please note in the space below any particular factorsNUM inBER relation to this patient DAYTIME YES NO Do you consider that it is prudent or necessary for the applicant to undergo a practical driving assessment? DAYTIME haWalveke reasonablerville, 5081 cause. to believe that tPostalIhe declare applithaARE addressctan would YOUthatt is sufferin CURRENTLY affec to if thedifferentt ghis from orbest BEINGher a p ofabili hyfrom TREATED simyctyal t oorknowledgeabove drive men BY tsafelANYal illness y.OTHER DAYTIMEthe, disabili DOCTOR abovety or OR informationdefi SPECIALISTciency FOR is ANYtrue REASON? and correct and that I have madeGPO Box the medical Requires a practical driving test aware...... SIGNATUR of (eg. limbE mobility, concentration span, etc). YesNo Yes No DATE ...... /...... /...... ARE YOU CURRENTLY BEING. TREATED BY ANYIfApServiceIf you SIGNATURESUBURB/TOWN plyouOTHERic canonsi SAansweredts DOCTORwd Centreerho th hoatld t ORheor a"Yes", l appicencemailSPECIALISTli cait other ntapproximatelyto is GPO tFOR than to ANY dBox arive b asicREASON? y1533,ou “ca orhowr” t Adelaidehelicence appmanyli acare ntSA hoursreqPOSTCODE sho 5001.uireuld per reto InYEStu u dayrnndeither ter he go do NOc case, oma youpplra eteditcti drive?iscalIn PHONEDATE signingrecommendedc derrivinti c this No.gHours:a form teassessment...... /...... /...... in you person consent that to toa youyourt agean doctor keep 85 releasing y Rea copy gandistra every fortion Medicalthat Practitioner’s the Driving Assessor signature should be made awareSUBURB/TOW of (eg. limbN mobility, concentration span, etc). DAYTIME POSTCODDateE PHONE No. thatSUBURB/TOWN would affect his or her ability to drive1. safel1533,HaveAREy. YOU Adelaideyou CURRENTLY consulted SA POSTCODE5001. BEING any TREATED medical BY practitionerANY OTHERPHONE DOCTOR No. within OR theSPECIALIST last 12 FOR months ANY REASON? that the medical practitionerYES NO completing this form does NOTE:SUBURB A/TOW practicalN driving assessment cannotNOTEAD beDRES : undertakenA practicalS driving if the assessmentP applicantOSTCOD cannotE is considered be undertaken to if bethe medicallyPapplicantHONE No is .consideredor psychologically to be medically or psychologically unfit to drive.If you consider that the applicant is t topractitioner driveIfanyearyour yoydou uLi therea cownoronsiensin the completing dftrecords. appger Cen .th Howliatcatre tntheever or sho app Service, iulthisf liyoudca rent tuformcSA onsiderisrn Centreun the t aware c titoom or prd riveplmaudete enofil y itInoudt signingortanycero a nereti POthis creqmedicalcateess form Buaroxes in youy t1, edyperson consento Wau to conditionmlke imme ayto trv youro recommen illa ndie,doctor at50e 81.releasingly ythat Rret egisdu arn pItr I racticanhavetathe eitherion ctoom the l andd ca pRegistrarrivinlese,te drugsgitd of aiscer ssessmentMotor retci ommended Vehicles,cateor medication to anya t medicalanPOy t haag informationBoxte you 1, that kee thatp Ia use. NOTE: A practical driving assessment cannot be undertaken...... if the applicant is considered to be medically or psychologically unfit to drive. Email address (if available)Please provide the nameto of the medical Registrar of Motor practitioner Vehicles, any medical or treating information specialist that mayIn signing a ect this your form ability you to consent drive safely. to your doctor releasing ADDRESS If recommending...... a practical driving assessment, please note in the space below any particular factors in relation to this patient that the IfanDriving yod uLi c onsiAssessorensindger shouldCen thatt ret behe or made app Service licant SA is Centreun tI consent to or dcWalirres rivenotmaopkeyil pecy ifouknow torrvto totiveill ay e,reoumy 50POoreqr foabout? 81t medicalwnBheuoxes claret .1,ed css orWa to ofds. lkeimme practitionerlicrvenillcdie,e athe50e81.ldly bret y ut heand/orrnI ntahep eitherpl ciomca myn capt.le se, treatingte dit iscer reti commencat specialiste to dedPO th atBreleasingox you 1, keep a toto the the Registrar Department of Motor Vehicles, any medicalof Planning, information that Transport and FOLD POSTAL ADDRESS (If di erent from above) IfDo recommending...... you recommend a practical conditions driving assessment, be placed please on note the in applicantsthe space below driver’s any particular licence? factors in relation to this patient that the Driving ______Assessor should be made Walcopkey frvorill ye,ou 50r o81wn re. cords. may a ect your ability to drive safely. awareSIGNATUR...... of (eg. limbE mobility, concentration span, etc). DATDAYETIME...... /...... /...... POSTAL ADDRESS (If di erent from. above)IInfrastructure declareApplicants that towhoany the holdmedical best a licence of information my other knowledge than arelating basic the “car” above to licence my informationability are required to drive to is undergo true safely. and amay practical a ectcorrect your ability driving and to drive that assessmentsafely. I have at made age 85 theand medical If yes, please note your recommendations in ...... the space below. DAYTIME ...... /...... /...... ApIfService youSIGNATUREplic canonsi SAts wd Centreerho th hoatld t heor a l icenceappmailli cait other ntto is GPO t than to dBox arive basic y1533,ou “ca orr” t Adelaidehelicence appli acare ntSA req sho 5001.uireuld reto Intu u ndrneither terhego ccase, oma prapl itcetedti iscal DATErecommended c derrivinti cga teassessment...... /...... /...... in person that atoyout agean keep 85 y Rea copy gandistra every fortion MedicalawareIf ...... SIG Practitioner’srecommending NofATUR (eg. limbE mobility, a signaturepractical concentration driving span, assessment, etc). SUBURB/TOW please noteN in the space below any particular factorsDAT Ein relation...... /...... /...... P OSTCODtoDate this patientE . PHONE No. SIGNATURE everyARE YOU year CURRENTLY thereafter. BEINGHowever, TREATED if you BY consider ANY OTHER it prudent DOCTOR or OR necessary SPECIALIST you FOR may ANY recommend REASON? a practical driving YESassessment NO at any Should a licence be issued subject to conditions? POSTCODE No Yes IfAp yopluic canonsits wderho th hoatld the a l appicenliceca otnther is t than toIpractitioner have d arive bayearanyour siy dmadeouc Li“thereaca ownorcensinr” the l icencompleting theftrecords. appger ceCen. Howmedicalli acaretrent everreq or sho uService, irediulthisf practitioneryoud reto tuformcSA undonsiderrn Centre terhe goaware c it oma orpr pcompleting plraudmaetect enofilic itdtal DATEortanycer odrivin neti PO cmedicalcateessg thisBaaroxssessmen...... /...... /...... iny 1, ypersonformo Wau conditionmlkeayt tatawarervo recommen illaganYESe,e 50 8 5 81. yof that R egisNOdany an a pdItr Iracticanhave atevermedical eitheriony l andd carivinse, condition drugs git aisssessment recommended or medicationthat at an Iy t haveaghaet you andthat keep drugs Ia use. or medication Medical SUBURPractitioner’sB/TOWN name ...... PHONE No. ARE YOU CURRENTLY BEING TREATED1. BY ANYyearageHaveSIGNATURE OTHER irrespectivetherea you DOCTORft erconsulted. How of ORtheever SPECIALIST class, i fany you of cmedical licenceonsider FOR ANY heldit prpractitioner udREASON? byen thet or applicant.necess withinary you the may lastrecommen 12 monthsd a practica thatIn DATEsigningl d rivinthe thisg formmedical a...... /...... /...... ssessment you consent practitioner to ayourt an doctory ag releasinge completing this form does that the Driving Assessor should be made aware...... of (eg. limb mobility, concentration span, etc). anyeard Li therecensinaftger Cen. Howtreever or Service, if you cSAonsider CentrethatI consent it orpr cirres Imaud opuse.entilypec if torto ortIotive y consentnecessaryoumy POor fo t medicalwnBheox clare 1,ytocouss Waor of ds.mymlke practitionerliaycrv en medicalreillcce,eommen he5081.ld b practitioneryd t aheand/or prI naacp eitherplticaInica signinglmy nd cat.rivin se, and/orthistreating g itform aisssessmen reyouc consentommenmy specialist treatingtot atyourd anyed doctor th age at releasingreleasing specialist you keep a toto releasing the the Registrar Department of Motor to Vehicles, the anyDepartment medicalof Planning, information that for Transport Infrastructure and and FOLD If yes, please provide details below: Provider Number FOLD ...... cirresopypec fortive you or fo twnhe clarecssords of l.icence held by the applicant. to the Registrar of Motor Vehicles, any medical information that may a ect your ability to drive safely...... FOLD Transport2.InfrastructureSignatureApplicantsnotPlease know any list whomedicalany about?all theholdmedical medications aPleaseinformation licence information provide other thatthe thanrelating name you arelating basic oftake to “car”medical my (prescribedto licence ability my practitioner ability are to required ordrive to orotherwise). treatingdrive safely.to undergo safely. specialist Attach a practical list if necessarydriving assessment Date at age 85 and ...... SIGNATURE DATE ...... /...... /...... Applicants who hold a licence other than a basic “camayr” a ect licence your ability are to req driveu iresafely.d to undergo a practical driving assessment at age 85 and every DoSIG youNATUR recommendE conditions be placed on the...... applicants driver’s licence? DATE ...... /...... /...... ______. every year thereafter. However, if you consider it prudent or necessary you may recommend a practical driving assessment at any Further...... comments on medical condition(s) affecting safe driving are attached. Applicants who hold a licence other than a bayearsic “thereacar” licenfterce. How are everrequ, iredif you to c undonsiderergo it a pr praudctenicalt or drivin necessg aarssessmeny you mtay at recommen age 85d an a dp racticaevery l driving assessment at any age MedicalIf Practitioner’syes, please note your name recommendations in ...... the space below. Pleaseage SIGNATUREnote: irrespective Your ofmedical the class practitioner of licence held hasby the a legalapplicant. obligation to inform the RegistrarDATE ...... /...... /...... if they believe that a person they have Practice ...... Address ...... yearSIGNATURE thereafter. However, if you consider it prirresudentpec ortive necessary of the cla youss of m liaycen receommen held byd tahe pr aacpplticaicaDATEl dnt.rivin g a...... /...... /...... ssessment at any age Should a licence be issued subject to conditions?...... ProviderYesNo NumberYes No FOLD IMPORTANT NOTES FOR THE MEDICAL PRACTITIONER ...... irrespective of the class of licence held examinedby the applica isnt. suffering from a medical condition such that they endanger the public if they drove. FOLD Signature Date IIf certify yes, please that I providepersonally details examined below: the above...... named patient in accordance with the “Assessing Fitness to Drive” guidelines. If the Section 80 of the Motor Vehicles Act 1959 requires certain applicants for a driver’s licence to provide medical evidence of the ir tness ...... Section 80 of the Motor Vehicles Act 1959 requires certain applicants for a driver’s licence to provide medical evidence of their ...... 2. toPlease drive. list all the medications that you take (prescribed or otherwise). Attach list if necessary applicant holds a driver accreditation, I have...... considered that they are medically and psychologically fit to drive a public passenger PleaseA person note: must Your not, medical in providing practitioner information, has a legal obligation make a statement to inform the that Registrar is false if or they misleading. believe that Penalties a person theyapply. have Practice ...... Address ...... IMPORTANT NOTES FOR THE MEDICAL PRACTITIONER vehicleTelephone and...... Numberhandle passengers. Facsimile Number E-mail Address IMPORTANT NOTES FOR THEexamined YouMEDICAL are is req sufferinguest edPRACTITIONER to c ompfromlete athe medical Medical aconditionnd Eyesight Cersuchti c thatate over theyleaf afendangerter referring theto the publicstanda rdsif theycontained drove. in the National ...... Please3. IMPORTANTTransSeHave cnote:tionpor you80t Commission Yourof beenthe Motormedical NOTES the pu V ehicdriverblic practitionerales tionFORA ofct” 1 Assessin a9THE59 vehicle req MEDICALhasugires Fit involveda cerness legalta into appDrive obligationPRACTITIONER inlica ants ”crash w forhicha driverintois avai theinform’slablelicen lastfromce 5the t oyears? Austp roviRegistrarroade dsmedionYescal (0if2) ethey vid926ence4 7088believe ofNo thoreat thatir t aness person they have ...... DEC...... LARATION Section 80 of the Motor Vehicles Act 1959 reqNationaluires certa Transportin applica ntsCommission for a driver’s publicationlicence to p rovi“Assessingde medical Fitness eviden toce Drive” of the whichir tness is available from Austroads on (02) 9264 7088 ...... examinedwwwSetoSectionIf cdYes,tionrive.a us is.80 80pleaset rosuffering o adfof the s.thec Motor omprovide Motor.au from .Vehic Vehicles detailsl esa Amedicalct 1Act959 1959 req conditionuires requires certain certainsuch applica that applicantsnts for they a driver formay ’sa licendriver’s endangerce t olicence provi dethe to medi providepubliccal evid medicalifence they o fevidence drove.the ir of t theirness ...... to drive. A personor at www.austroads.com.au. must not, in providing information, make a statement that is false or misleading. Penalties apply. Telephone...... Number Facsimile NumberNAME OF MEDIC AL E-mail Address PROVIDER UnderYouto drive are se. reqctionues 14ted8 of to thecomp Motorlete theVehi Meclesdical Act and youEy haesighve at legalCerti c obligatate overionle toafinform after ref theerrin Regg toist trarheofst anMotordards Vehicles contained if y inou the National Medical Practitioner’s signature Date You are requested to complete the Medical aIMPORTANTnd Eyesight Certi c NOTESate overleaf FOR after ref THEerrin gMEDICAL to the standards PRACTITIONER contained in the N ational PRACTITIO...... NER (Please Print) NUMBER haTransYouUnderve a reasonablepreor reqsectiont Commissionuested c148ause to cofomp topu thebelieveblleteic Motoration the tha ”Me tVehiclesAssessin tdihecal ap aplindg cAct FitanEyesightness youis sufferin thave oCerDriveti g ca fromalegalte” overw a hiobligation pchhyleafsiis caf avaialter orlable ref mentoe rrininformfromtalg illnesstoAust t hetheroa, st disabi Registrarandsdaonlrdsit(0y 2)coron 9ofdef26tained Motor4icienc 7088 iny ortVehiclesheat Na tionalif you ...... DECLARATION IMPORTANTTransport Commission NOTES publica tionFOR” Assessin THE MEDICALg Fitness to Drive PRACTITIONER” which is available from Austroads on (02) 9264 7088 or at FurtherDECLARA commentsTION on medical condition(s) affecting safe driving are attached. SECTION3. TranswwwSetHavehacttionwould.apor us you80 t2:t roCommission o affecadf beentheIMPORTANTs.ct Motor omhis the.auor pu. herV ehicdriverbl abiliicalestionty A ofctt ”o 1 driveAssessina9 59 NOTESvehicle reqsafelugiresy. Fit involved cerness taFOR into appDrive inli caTHE ants ”crash w for hi chaMEDICAL driver inis avaithe’slablela licen blelast fromce 5 t oyears? Aust pPRACTITIONERroviroade ds medi onYes cal(02) e vid926ence4 7088 ofNo thore at ir tness SECTION 4: EYESIGHT CERTIFICATE (Must be completed in all cases) DEC...... LARATION wwwSection.aus 80tro oadf thes.c Motor om.au .Vehicles Act 1959 reqNationaluires certa Transportin applica ntsCommission for a driver’s publication licence to p rovi“Assessingde medical Fitness eviden toce Drive”o f the whichir tness is available from Austroads on (02) 9264 7088 ...... ADNAMEDRES OFS MEDICAL PROVIDER UnderwwwIftoIfyo dYes,riveu.a cusonsi se. pleasecttroiondader s.14 thc8atom provideof the.authe app. Motorli cadetailsnt V isehi uncles t t Acto drive you y haouve are a reqlegalues obligatted toion imme to informdiately tretheu Rern gtheist rarcomofp Motorleted cer Vehiclesti cate ifto you PO Box 1, Medical NAPractitioner’sME OF MEDICAL name PRACTITIONER (Please Print) PROVIDER NUMBER Underto drive se. ction 148 of the Motor Vehicles4. ActorIs you drivingat ha www.austroads.com.au.ve a legala significant obligation t opartinform of tyourhe Re goccupationistrar of Motor or Vehi voluntarycles if you work (e.g. courier driver or community bus driver)? Yes No NAME OF MEDICAL PROVIDER TheThe Registrar RegistrarhaUnderYouWalveke a reasonablererv se ill req ctofe,ion u50of esMotor81 14t edMotor c8ause of to. the cVehiclesomp to VehiclesMotorbelievelete theV tehirequiresha Me requirestc lestdihecal Act ap apli ndyou certainc certainanEy haesight isve sufferin a applicantst legalCer applicantsti g cobligat fromate over ionafor p hyforle t oafasi inform cafdriver’saalter driver’s or ref mentheerrin Re licence,talg glicence, illnesstoist trarhe , ofst ordisabi anMotor or licenceda lrdslicenceit y Vehicles corondef holders,tained iholders,cienc if y inouy t he to Nato provide providetional evidence evidence of of their their fitness 11. If the patient has one or more of the following eye or vision conditions, please tick condition/s. PRACTITIONER (Please Print) NUMBER DAYTIME haYouve a reasonablere requested cause to comp to believelete the tha Met tdihecal ap aplindc anEyesight is sufferint Certig cfromate over a phyleafsi cafalter or ref menerrintalg illnessto the, st disabiliandardsty corontdefiaineciend incy the N ational GPO Box PRACTITIONER (Please Print) NUMBER tofitness drive.haTranstIfUnderIfha you vPlease:you tetowould reasonablep c oronsi sectiondrive.answeredt Commissiond affecer th tPlease:c148athisause the or "Yes",of topuapp her the believebl liabiliicca Motora tionntapproximatelyty ist hat ”o t tdriveVehiclesAssessin tothe d arivesafelppli yg couActy. Fit an orthowness youis t hesufferin t haveoappmany Driveli caga fromnt legalhours sho” w a hiulobligation pchd hyper re siistu c avai aldayrn or tlablelahe blemen todo c om informfrom tyoualpl illness eted Aust drive? the croa,er disabi Registrartids c onHours:alteit (0y in 2)orperson 9 ofdef26 Motor4icienc 7088 to any or Vehicles at y Reg ifistra yoution DECSUBURB/TOWLARATIONN POSTCODE PHONE No. tTranshat wouldport Commission affect his or pu herbl abiliicationty t ”o driveAssessinsafel1533,gy. Fit ness Adelaide to Drive SA 5001.” which is availablelable from Austroads on (02) 9264 7088 or at FurtherDECLARA commentsTION on medical condition(s)ADDRES affectingS safe driving are attached. Ifanwwwthayodt uLiwould.a cusonsiensintro daffec adger Cens. thct atomhistre the .auor or app. her Service liabilicantSAty is t Centreoun drive t to or safeldrivemay.il y itou to arePO req Buoxes t1,ed Watolke immervilldie, at50e81.ly returnI nthe either com caplese,te itd iscer retci ommendedcate to PO thaBoxtyou 1, keepa Cataracts Diplopia Glaucoma Macular Degeneration ADDRESS Ifwwwyou.a cusonsitrodaders. thcatom the.au app. licant is un• t•refer trefero drive to to y sectionou the are National req 1ues thatted to Transporthas imme beendiate lyCommission’scompleted return the com by ppublication leyourted cer patient;ti cat e“Assessing to PO Box Fitness 1, to Drive 2016” private standards for light vehicle licence. Medical Practitioner’s practice address ADNAMEDRES OFS MEDICAL PROVIDER cUnderIfWalop yokeyu f corrv onsi seill ycte,ouiond 50rer o81 14wn th8at ofre .the ctheor appds. Motorlicant V isehi uncles t t Acto drive you y haouve are a reqlegalues obligat ted toion imme to informdiately tretheu Re rn gtheist rarcom ofp Motorleted cer Vehiclesti cate ifto y ou PO Box 1, Poor Night Vision Retinitis Pigmentosa Other condition which may impair their ability to drive (please specify) NAME OF MEDICAL PRACTITIONER (Please Print) PROVIDER NDAUMBEYTIMRE WalUnderkerv seillcte,ion 5081 148 of. the Motor Vehi• cles4. Irefer declare TheAct Is youto guidelinesdriving hathethatve Nationala to legala significantthe are obligat best availableTransportion of t opart myinform from ofknowledgeCommi tyourhe AustroadsRe gsoccupationis sion'strar the of Motorpublication atabove www.austroads.com.au or Vehi voluntary informationcles “Assessingif you work is true(e.g.Fitness andcourier to correct Drive driver 201and or6 ”thatcommunity private I have standards madebus driver)? the for medical lightYes vehicle No licence. SIGNATURE DAYTIME DATE ...... /...... /...... haApIfWalService youvpleke icreasonable crvanonsi illSAte,s wd 50Centreerho81 th ho catauseld .t heor a l toicenceappmail believeli cait otherntto ist haGPO t thant tothe dBox aarive pbpliasic y1533,couan“ca ort r”is tAdelaide he licsufferin ence appli acagre fromntSA req sho 5001.u aireul pdhy reto siIntu cual ndrneither or terhe men go ccase,om a tpalrapl illness itcetedti iscal recommended c,der disabirivinti cga lteaitssessmenty in orperson def thaticienc atoyout ageany keep 85 y Rea copyg andistra every fortion Medical PRACTITIONERPractitioner’s (Please signature Print) SUBURB/TOWN NUMBER POSTCODDateE DAPHONEYTIM NoE . Ifhayoveu reasonable consider th catause the toapp believelicant istha tt tot practitionerhe d(your ariveppli ycouan assessmentort is the sufferin completing applicag fromntmust sho a ul this pbedhyresi undertakentuformcalrn or the menaware comtalpl illness ete inofd accordance anycer, disabiliti medicalcatetyin or person defiwith conditioncien t othecy an guidelines); ythat Regis Itr haveation and drugs or medicationGPO that Box I use. Visual Field Defect SUBURB/TOWN POSTCODE PHONE No. yearantIfyourIfha you dyout Liwouldtherea ownconsiensin answered dftrecords.affec ger Cen . th Howt athistre teverhe or or"Yes", app her Service, if youliabilica ntapproximately cSAtyonsider is t Centreo t drive to d itrive or prsafeludma youy.enil it t orhow orto t henePO cappmanyess Bliaroxcay 1,nt yhourso Washou mlkeulayd rv perrecommen reille,tu 50dayrn 81.the do dcom a youpplIracticaneted either drive? l c der carivintise, c Hours:ga itte a isssessment in re personcommended toat any tagha yety Reougistra keepation SUBURB/TOWN POSTCODE PHONE No. anthatd Liwouldcensin affec g Cent histre or or her Service abiliSAty tCentreo driveI(your consent orsafelcirres1533,maop assessmenty.ilypec if torto tAdelaideotive y oumy POor fo t medicalwnBheox must SAclare 1,css Waor5001. ofds. belke practitioner licrv enundertakenillce,e he5081.ld by t heand/or I innap either placcordanceica myn cat. se, treating it is re withcommen specialist theded guidelines); th atreleasing you keepa to the Department of Planning, Transport and Telephone Number Facsimile NumberADDRESS E-mail Address FOLD Ifan yod uLi consiensindger Cen thattre the or app Servicelicant SA is Centreun t to or d rivemail y itou to a re PO req Buoxes t1,ed Wa tolke immervilldie, at50e81.ly ret urnI nthe either com caplese,te itd iscer retci ommendedcate to PO tha Boxtyt you 1, keepap a copy for your own records. • pleaseApplicants complete who hold all ofa licence sections other 3 thanand a5; basic “car” licence are required to undergo a practical driving assessment at age 85 and Note: If the patient has one or more of the above conditions and the eyesight standards are not met (aided) an Optometrist ADDRESS SIGNATURE DATE ...... /...... /...... If you consider that the applica. nt is un• tInfrastructure to dcWalriveopkey y fouorrvill aye,reou 50 reqrany o81wnues medicalret.ed cor tods. imme informationdiately return t herelating comple tetod cermyti abilitycate to toPO drive Box 1, safely. if youApevery areplic anyear familiarts wthereafter.ho ho ldwith a lHowever,icence your other patient's if thanyou considera b asicfull“ camedical itr” prudent licence history,a reor reqnecessaryuire youd to youu onlynd ermaygo need arecommend pra ctotical completedrivin a practicalg assessment the driving parts at age assessmentof 85 section and at every 3any relevant to the patient's or Ophthamologist must complete the Eyesight Certificate. SIGNATURE DATE ...... /...... /...... DAYTIME ApWalplkeicrvanillte,s w 50ho81 hold. a licence other than•I declarepleasea basic “ cathatcompleter” licen toce the are section reqbestuired of 4t o myif und your knowledgeergo patienta practical thehas drivin aboveag vision assessmen information or teye at ag disorder,e 85 is trueand or ever and isy required correct andto wear that glasses I have madeor corrective the medical lenses; PleaseMedical complete Practitioner’s if a specialist name has assessedSIGNATUR any ofE the patient’s conditions in additionDAYTIM Eto the treating medical practitionerDATE ...... /...... /...... medicalyearApIfServiceage youpl irrespective thereaicconditions canonsi SAts wdft Centreerho . th Howho atofld t andtheeverheor a l icenceappmail class, iallf youli cait of othernt toc licenceonsider issections GPO t than to dhelditBox arive prb asic4ud y1533,by ouanden “ cathe tor orr” t 5; Adelaideheapplicant. licneence cappessliar acarey ntSAy reqo shou 5001. umireulayd recommen reto Intu u ndrneither terhego dccase, om aa ppraplractica itcetedti iscal recommended lc dderrivinrivinti cgga te aassessmentssessment in person that atoayoutt agean keepy 85ag ye Rea copy g andistra every fortion Medical Practitioner’s signature SUBURB/TOWN POSTCODDateE PHONE No. yearIf youthere consiaftder .th Howat teverhe app, if yolicaunt consider is t to practitioner ditrive prirresud youentpec or ortive the necessarycompleting oappf thelica cla ntyouss sho ofm ul lithisaycden re rec tuformeommen hern ldthe baware ydc om taheprpl aacpete plofticadica lanycer dnt.rivint i medicalcateg assessmen in person conditiont tato aanyn age ythat Regis Itr haveation and drugs or medication that I use. FOLD your own records. Additionally, if your patient‘s visual acuity with corrective lenses in the better eye or with both eyes together is worse than 6/12, or SUBURB/TOWN POSTCODE ProviderP HONENumber No. irrespective of the class of licence he•ld bify youtheyearan app dare Litherealiccant. ensinnotft gerfamiliar Cen. Howtreever or Servicewith, if you your cSAonsider Centre patient’s it or pr udmaenil ittfull orto ne medicalPOcess Baroxy 1,yo Wahistoryu mlkeayrv recommenill e,please 5081. d complete a pIractican eitherl d ca rivinallse, gofit a is ssessmentsections re commended a 3,t an 4y t andaghaetyt you 5; keepap a (Not required if a separate report has been provided or a specialist has completed the declaration above). FOLD • provide comment in the notes section on the inner page on how well controlled your patient’s condition(s) are and compliance and Licensing Centre or Service SA CentreISignature consent orcirres maopilypec if torto totive y oumy POor fo t medicalwnBheox clare 1,css Waor ofds.lke practitioner licrvenillce,e he5081.ld b y t heand/orI nap eitherplica myn cat. se, treating it is recommen specialistded th atreleasing you keepap a to the DepartmentDate of Planning, Transport and FOLD FOLD FOLD their visual field is worse than the criteria contained in the Assessing Fitness to Drive guidelines, an Optometrist or Ophthalmologist copy for your own records. • InfrastructureprovidewithApplicants any comment medication whoany holdmedicalin the a taking.licence notes information other section than on arelating basic the “car” opposite to licence my ability pageare required onto drivehow to undergo wellsafely. controlled a practical driving your patient’s assessment condition(s)at age 85 and are and compliance SIGNATURE DATE ...... /...... /...... PleaseAp note:plicants Your who ho medicalld a licence practitioner other than a basic has “ca ar” legal lic ence obligation are required to to u ndinformergo a p theracti calRegistrar driving assessment if they believe at age 85 that and a everyperson they have must complete the Eyesight Certificate. Practice SIGAddressNATURE DATE ...... /...... /...... Applicants who hold a licence other thanwith a baevery anysic “ca yearmedicationr” licen thereafter.ce are req taking; However,uired to und if eryougo considera practical it drivin prudentg assessmen or necessaryt at ag youe 85 may an recommendd every a practical driving assessment at any SpecialistMedical Practitioner’s name: name examined yearage irrespectivetherea is sufferingfter. How of theever from class, if you ofa c licencemedicalonsider held it pr conditionud byen thet or applicant.nec suchessary thatyou m theyay recommen endangerd a practica the publicl driving aifssessment they drove. at any age year thereafter. However, if you consider it prirresudentpec ortive necessary of the cla youss of m liaycen receommen held byd tahe pr aacpplticaical dnt.rivin g assessment at any age Visual acuity Right Left Together FOLD • FOLD section 4 (Eyesight Certificate) must be completed in all cases. Provider Number irrespective of the class of licence held by the applicant.cant. FOLD FOLD Signature Date Type of specialist: A person must not, in providing information, make a statement that is false or misleading. Penalties apply. Uncorrected 6/_____ 6/_____ 6/_____ Telephone Number Facsimile Number E-mail Address Practice Address Please note: Your medical practitioner has a legal obligation to inform the Registrar if they believe that a person they have Corrected (glasses/contacts) 6/_____ 6/_____ 6/_____ Conditions assessed: WHATexamined TO is sufferingDO WITH from THEa medical COMPLETED condition such that MEDICAL they endanger ASSESSMENT the public if they drove. SECTION 3: MEDICAL EXAMINATION REPORT - For all "Y es" answers provide comments on the page opposite. Does your patient meet the eyesight standards in the Assessing Fitness to Drive 2016? No Yes Specialist’s signature: Date: / / A person must not, in providing information, make a statement that is false or misleading. Penalties apply. (refer to vision and eye disorders in “Assessing Fitness to Drive” publication) 1. •BLACKOUT Return to GPO Box 1533, Adelaide 5001 or any Service SA Customer Service7. NEUROLOGICA Centre L / NEUROMUSCULAR CONDITIONS Telephone Number Facsimile Number E-mail Address ISMF Classification when complete - Has your patient experienced a blackout? Does your patient have a neurological / neuromuscular condition? If more than one specialist has undertaken an assessment, please provide your details in the section above or attach a report if applicable. • Enquiries: 13 10 84 Are glasses or contact lenses required for driving? No Yes If Yes, please complete the following. SENSITIVE: MEDICAL - I3 - A3 Date of most recent episode: __ / __ / __ If Yes, please complete the following. Please tick the relevant condition(s): 2. CARDIOVASCULAR DISEASE If you are not completing the other sections of this form please provide your details. Brain Aneurysm Muscular Dystrophy Does your patient have a cardiovascular condition? If Yes, please complete the following. Cerebral Palsy Parkinson’s Disease Please tick the relevant condition(s): Dementia Seizure Epileps*y*** Space-occupying Lesion (brain tumour) Medical Practitioner / Optometrist’s Name Date Coronary Artery Bypass Grafting (CABG) Head Injury Stroke Dilated Cardiomyopathy Multiple Sclerosis Subarachnoid Haemorrhage Heart Failure Cardiac Aneurysm Medical Practitioner / Optometrist’s Signature Provider Number Contact Number Cardiac Arrest Heart Transplant *Date of last episode: __ / __ / __ Cardiac Pacemaker Hypertrophic Cardiomyopathy Congenital Heart Disorder Implantable Cardioverter Defibrillator ADDITIONAL NOTES: Provide comment to each Yes condition(s) below including reference to the specific condition (e.g. 4. Diabetes). Other Cardiovascular: ______8. PSYCHIATRIC CONDITION 3. HYPERTENSION
Does your patient have blood pressure consistently greater than 200 If Yes, please complete the following. systolic or greater than 110 diastolic (treated or untreated)? Please tick the relevant condition(s): Anxiety Post Traumatic Stress Disorder (PTSD) Blood pressure readings: Bipolar Affective Disorder Schizophrenia Systolic: ______Diastolic: ______Chronic Depression Tourette’s Syndrome Personality Disorder Other: ______4. DIABETES Does your patient require medication? No Yes Does your patient have diabetes controlled by medication? If Yes - is your patient compliant with medication?
If Yes, please complete the following. Diabetes controlled by Insulin Tablet 9. SLEEP DISORDER Is your patient compliant with medication ? Does your patient have a sleep disorder? If Yes, please complete the following. Does the patient experience early warning symptoms of hypoglycaemia?
Date of last episode: ______Other: ______Any end organ effects: please specify: ______
10. SUBSTANCE MISUSE 5. HEARING LOSS Does your patient currently misuse alcohol or drugs? Does your patient have severe hearing loss? If yes, complete the following. Refer to ‘Assessing Fitness to Drive’ publication for definition of ‘severe hearing loss’. Alcohol Illicit drugs Prescription drugs 6. MUSCULOSKELETAL CONDITION Does your patient have a musculoskeletal condition? Any end organ effects: (please specify)______If Yes, please complete the following. Please tick the relevant condition(s): Severe Arthritis Other Musculoskeletal Conditions Limb Is the condition likely to affect driving?