Track-back: Manager | The Standard Toolbox

Annual Health Declaration for Drivers

A: PERSONAL DETAILS
Surname:	Date of Birth:
Forenames:	Tel No (inc code):
Address 1:
Address 2:
Address 3:
Postcode:
Position:	Dept:
B: YOUR HEALTH
Have you suffered from any of the following during the last 12 months? Tick box
1. Epilepsy			No		Yes
2. Fit(s) or blackouts			No		Yes
3. Severe and recurrent disabling giddiness			No		Yes
4. Diabetes controlled by insulin			No		Yes
5. Diabetes controlled by tablets			No		Yes
6. An implanted pacemaker or defibrillator			No		Yes
7. Angina (heart pain) which is easily provoked by driving			No		Yes
8. Persistent alcohol misuse or dependency			No		Yes
9. Persistent drug misuse or dependency			No		Yes
10. Parkinson's disease			No		Yes
11. Narcolepsy or sleep apnoea			No		Yes
12. Stroke, with any symptoms lasting longer than one month, recurrent 'mini strokes' or TIAs			No		Yes
13. Any type of brain surgery, severe head injury involving in-patient treatment, or brain tumour			No		Yes
14. Any other chronic neurological condition			No		Yes
15. A serious problem with memory or episodes of confusion			No		Yes
16. Serious psychiatric illness or mental ill health for example diagnosis of anxiety/depression which required treatment from your GP/Specialist			No		Yes
17. Any visual condition affecting BOTH eyes or affecting your peripheral vision (visual field) (excluding short/long sight or colour blindness)			No		Yes
18. Any persisting limb problems which requires your driving to be restricted to certain types of vehicle or those with adapted controls			No		Yes
19. Sight in one eye only			No		Yes
20. Visual problems affecting either eye			No		Yes
21. Angina, other heart condition or heart operation			No		Yes
22. Any form of stroke, including minor or TIA			No		Yes
C: DECLARATION AND AUTHORISATION
I confirm that the information given above is a true and accurate statement.  I understand that if I have declared any of the conditions listed above, further medical investigations may take place.
Signature:			Date:

Courtesy of the Royal Society for the Prevention of Accidents (RoSPA)

---

All of the documents can be obtained from us in a word format, so that they can be personalised and edited to suit your company or business. This service is free of charge, on request.

Call us now on