Personal Details * Denotes required field
* Title:
* Forename:
* Surname:
*Driving Licence Number:
*Date Driving Licence Obtained:
*National Insurance Number:

* Date of Birth:
* Address:		* Home Tel:    Evening Tel:    Mobile Tel:
*Postcode		Email Address:

Medical questionnaire : Medical in Confidence
Please tick 'yes' to all applicable questions and complete the additional information required.	Yes
Do you have any difficulties reading a number plate at 20m with or without spectacles? You must check this before you answer.
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you wear spectacles for distance vision?
Please indicate when you these were issued and the date of your last eye test. If it has been more than 2 years since your last eye test, please arrange an appointment with your Optician before completing this form.
Are you without sight in either eye?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you have double vision?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you have any eye problems which cannot be corrected by spectacles or contact lenses?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you have a physical disability affecting your arms, legs, neck or back?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Have you ever had any fit or seizure?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you suffer from Epilepsy?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Have you ever been unconscious for any reason or suffered prolonged or repeated dizziness or vertigo?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you have any problems hearing a normal conversational voice (with or without a hearing aid)?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you have Diabetes?
Please give full details of type and treatment.
Do you or have you ever had?
A heart attack
Angina
Palpitations
Heart Failure
Raised blood pressure
Any investigations/operations on your heart or blood vessels
No to all the above
Attention If you are taking medication for blood pressure or heart problems, you must provide evidence of the last 3 blood pressure readings, taken by your GP, signed on headed paper or compliments slip. This is a DVLA requirement. Without this, we are unable to process your application.
Have you ever suffered from any form of mental health problems?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Have you ever been dependent on alcohol, drugs or other substances?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you now or have you ever suffered from any brain or neurological problems e.g. stroke, brain haemorrhage, multiple sclerosis or brain surgery?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
Do you take any medication?
Please give list all medication
Do you have, or have you had any health problems not included in the previous questions?
Please give full details/dates, e.g. treatment/medication or if you have fully recovered
How often will you be driving?
Is your medical condition reportable to the DVLA? You must check this by following the link: https://www.gov.uk/health-conditions-and-driving
If you have answered Yes to the question above, please provide a copy of the letter from the DVLA as to the outcome of your medical investigation and fitness to drive. If you have lost your letter, you can obtain a copy by contacting DVLA directly.
Will you be carrying passengers?
Please provide details
* Signed:	* Date: