cc Medical examination report Driver & Vehicle fF a Group 2 (bus or lorry) licence Licensing For acice on how to fin this form, read the leaflet INF4D avaable at www.gov.uk/reapply-driving-licence-medical-condition ‘Agency Pease use black ink when you fil in this report. ras a Pe tok Smee eee Oana oon teers en eared Important information for doctors carrying ‘out examinations. Preece Perea Important: This report is only valid for inte inati Before you fil in this report, you must check the applicant's pee Car cane Le OL ‘identity and decide if you are able tofilln the Vision Name assessment on page 2. If you are unable to do this, you ‘must inform the applicant that they will need to ask an ‘optician or optometrist to fil in the Vision assessment, Examining medical professional Date of birth eal Address: Has a company employed you or booked yyou to canty out this examination? Yes|_| No|_] If Yes, you must give the company’s details below. IfNo’, you must give your practice address details below. Postcode (Refer to section C of INF4D) Contact number Company or practice address Email address Date first licensed to drive a bus or lorry Postcode Ifyou do not want to receive survey invitations by emall from L1ititt|t} DVLA, pleas tick box Company or practice contact number Your doctor's details (only fill in if di from examining doctor's details) ‘Company or practice email address GP's name ‘GMC recistration number Practice address Oe I'can confirm that Ihave checked the applicant's documents to prove their identity. Signature of examining doctor ‘Applicant's weight (Ka) ‘Applicant's height em) Postcode | Contact number Number of alcohol units consumed each week Units per week = Does the applicant smoke? yes[_]Nol_] Do you have access to the applicants full medical record? Yes|_|No|_) oa Important: Signatures must be provided at the end of this report 5 INVESTORS IN PEC?PLE™ |. We invest in people Gold 23ee Medical examination report Dr & Ve toersng ~~ Vision assessment Agency 1. Please confirm (/) the scale you are using to express the applicant's visual aculties. Snelen|_| Snelen exressed as adectral|_| LogMan|_] 2, The visual acuity standard for Group 2 diving at least 6/7.5 in one eye and atleast 6/60 in the other. (@) Please provide uncorrected visual acuities for each eye, Snellen readings with a plus (+) ‘of minus (are not acceptable. I 6/7.5, 6/60 standard is not met, the applicant may need further assessment by an optician. R L Yes No (6) Are corrective lenses worn for driving? [| [_] IFNo, go to a3. If Yes, please provide the visual aculties using the correction worn for driving. Snellen readings with a plus (+) or minus (-) are not acceptable. IF 6/7.5, 6/60 standard is not met, the applicant may need further assessment by an optician, a Je (©) What kind of corrective lenses are worn to meet this standard? Gissses|_] Contact lonses{_] Both together] (@) tlasoea are wor fr avin, i the ‘corrective power greater than plus (+}8 Yes. No dioptres in any meridian of eitherlens? [|_| [|_| Yes No (©) Iforrection is worn for driving, is it well tolerated? I No, please aive full details in Q7. Li] Is there a history of any medical condition that may affect the applicant's binocular field of vision (central and/or peripheral}? I Yes, please ive full details below. Yes No Ou If formal visual field testing is considered necessary, DVLA will commission this ta lator dato. 4. Is there aiplopia? = B (@)Is it controled? ict Please indicate below and give fll details in Q7. Patch or Glasses Other Glasses with with/without. (other please frosted glass |_| prism |_| provide details) |_| To be filled in by an optician, optometrist or doctor 5. Does the applicant report symptoms of any of the following that impairs their ability to drive? Please indicate below and give full details in Q7 below. (@) Intolerance to glare (causing incapacity rather than discomfort) and/or (©) Impaired contrast sensitivity and/or (6) Impaired twilight vision Uf OOO 6. Does the applicant have any other ‘ophthalmic condition affecting thelr visual acuity or visual field? If Yes, please give full details in Q7 below. Lif 7. Details or additional information Name of examining doctor, optician or optometrist undertaking vision assessment | confirm that this report was filled in by me at ‘examination and the applicant's history has been taken into consideration. ‘Signature of examining doctor, optician or optometrist Date of signature Please provide your GOG or GMC number Doctor, optometrist or optician’s stamp ‘Applicant's full name | | | Date of birth Please do not detach this page 2we Medical examination report Driver & Vehicle . Licensing Medical assessment Agency Must be filled in by a doctor 1 Neurological disorders Peed Please tek the appropiate boxes, ves. NO Pease name ppoptntebes) vee N5) | Doeate appt hee Qbeteerome? |) 4 disorder (s2e condtions in questions 110 11 below? |. | | IfNo, go to section 3, Cardiac a If No, go to section 2, Diabetes mellitus If Yes, please answer all questions below. If Yes, please answer all questions below and encose relevant 41. Is the diabetes managed by: Yes No Peseta poe (a) Insulin? oO oO Yes No Ifo, goto to 4. Has the applicant had any form of seizure? (| |_| Yes, please give date | (a) Has the applicant had more than started on insulin. ‘one seizure episode? ood (o) Are there at least 6 continuous weeks (b) If Yes, please give date of first and last episode. of blood glucose readings stored on ears a memory moter or metre? Oo ITNo, please ge deta In section 8, page 7. eee (0) Other injectable treatments? (© Is te applicant curently on oO (@) A Sulphonylurea ora Giride? ites, please in be medleatin section 8, page 6. ice eerste (d) Ifno longer If Yes to any of (a) to (e), please fill in treated, when did ‘the medication section 8, page 6. treatment end? (0 Diet ony? oO (¢) Has the applicant had a brain scan? It Yes, please gle detalsn section 9, page 7. () Has the applicant had an EEG? 2. (a) Does the applicant test blood glucose at least twice every day? OO Oo Ifyou have answered Yes to any of above, (0) Does the applicant test at times relevant {you must supply medical reports, to diving (no more than 2 hours before the start of the first journey and every 2. Has the applicant experienced 2 hours while driving)? dissociative/"non-epileptic' seizures? (0) Does the applicant keep fast-acting (a) t¥es, please give carbohydrate within easy reach date of most recent episode. i) See eee Coe oe poy carabaed Bay understanding of diabetes and the to occur whist drving? necessary precautions for safe driving? O Lé O Le 3. (a) Has the applicant ever had a hypoglyaemic episode? 2} IFYes, is there full awareness of hypoglycaemia? 3, Stroke of TIA? Yes IF Yes, give dete UO (a) Has there been a full recovery? Oo (0) Has a carotid ultrasound been undertaken? |_| (6) Yes, was the carotid artery stenosis >60% in ether carotid artery? (@) Is there a history of multiple strokes/TIAs? |) 4, Sudden and disabling dizziness or vertigo within the last year with a lability to recur? [_) 5. Subarachnoid haemorthage (non-traumatic)? [_) 4. Is there a history of hypoglycaemia in the last 12 months requiring the assistance of anather person? It Yes, please give details and dates below. Lee ee le LL | eS ee 5. Is there evidence of: Yes No (@) Loss of visual field? Oo (b) Severe peripheral neuropathy, sufficient tomperinbindon erase anieg? C] C] It Yes, please give details in section 9, page 7. Significant head injury within the last 10 years? 7. Any form of brain tumour? ‘8 Other intracranial pathology? 6. Has there been laser treatment or Yes No intra-vitreal treatment for retinopathy? et I1Yes, please give most recent date | of treatment. 9, Chronic neurological disorder(s)? 10. Parkinson's disease? 11. Blackout, impaired consciousness or loss of awareness within the last 10 years? OOOO0O OO OO OOo OODDDO neretstnme || CELE omen TETene eC me Is there a history or evidence of Yes No coronary artery disease? Oo It No, go to section 3b, Cardiac arrhythmia Yes, please answer all questions below and enclose relevant hospital notes. 1. Has the applicant ever had an episode Yes No of angina? of IFYes, please give the date ofthe last known attack 2 Acute coronary syndrome including Yes No myocardial infarction? oOo IFYes, please give date 3. Coronary angioplasty (PC)? Yes No ItYes, please give OO date of most recent intervention 4. Coronary artery bypass graft surgery? i ItYes, please give date, 6. If Yes to any of the above, are there any Yes No pphysical health problems or disabilities Oo (e.g, mobility, arthritis or COPD) that would make the applicant unable to undertake 9 minutes of the standard Bruce Protocol ETT? Please give detalls below. Der Cee) Is there a history or evidence of Yes No cardiac arrhythmia? Oo IfNo, go to section 3c, Peripheral arterial disease IfY¥es, please answer all questions below and enclose relevant hospital notes, 1. Has there been a significant disturbance of cardiac rhythm? (e.g. sinoatral disease, significant atrio-ventricular conduction defect, atrial futtor oF fibilation, narow or broad T° complex tachycardia) nthe last 5 years? |_| ‘2. Has the arrhythmia been controlled a Sallsfactorly for atleast 3 months? Oo 3. Has an ICD (implanted Cardiac Defirilato) or biventioular pacemaker with defibrilator/ V5 yg cardiac resynchronisation therapy defibrillator (CRT-D type) been implanted? OO 4. Has a pacemaker or a bivencuar pacemaker ee (CREP type) been implanted? oO ites: (a) Please give date of implantation, ee eed eee eran Caused the device tobe fed? oo (@) Does the applicant attend a pacemaker linc regularly? ] Le Cr ca Cette gk) Errata, o Is there a history or evidence of peripheral Yes No arterial disease (excluding Buerger's disease), =f) |) aortic aneurysm or dissection? I{No, go to section 8d, Valvular/congenital heart disease It Yes, please answer all questions below and ‘enclose relevant hospital notes. 4. Peripheral arterial disease? Yes No (excluding Buerger’s disease) [a] Yes No 2. Does the applicant have claudication? Oo IfYes, would the appicant be able to undrtako 9 [| ‘minutes ofthe standard Bruce Protocol ETT? Yes No eee Ls if Yes: OU (a) Site of aneurysm: Thoracic |_| Abdominal] {(b) Has it been repaired successfully? (c) Please provide latest transverse aortic diameter measurement and date obtained using measurement and date boxes. 4. Dissection of the aorta repaired successfully? Yes No IYes, please provide copies of alreports |_| |_| including those dealing with any surgical treatment, 5. Is there a history of Marfan’s disease? Yes No It Yes, please provide relevant hospital notes. [| {| Ci eines nice at ea Is there a history o evidence of valvular or congenital heart disease? HfNo, go to section Se, Cardiac other I'Yes, answer all questions below and provide relevant hospital notes. Yes No OU Yes No 1. Is there a history of congenital heart csease? [~~] Yes No 2, Is there ahistory of heat valve disease? ICI 4, te there ahstory of aortic stenosis? Yes No If Yes, please provide relevant reports an {including echocardiogram). Yes No 4, Is there history of embolic stroke? Od 5. Does the applicant curently have Yes No significant symptoms? OO 6, Has there been any progression either Yes No linially or on scans etc) since the last Yes No licence application? UU Applicant's full name Date of birth [| TT TTIs there @ history or evidence of heart failure? Yes. No If No, go to section 3f, Cardiac channelopathies| | | | I'Yes, please answer all questions and enclose relevant hospital notes. 1. Plase provide theNYHA class, [| it known, 2. Established cardiomyopathy? eaea NE IT Yes, please givo details in saction 9, page 7. [| [ | 3. Has a left ventricular assist device (LVAD) or Yes No ‘other cardiac assist device been implanted? (| [| 4. Aheart or heart/ung transplant? Ss ator heart/lung transplant oo Yes No 5. Untreated atrial myxoma? i ee eee Tad Is there a history or evidence of the Yes No following conditions? Oo If No, go to section 3g, Blood pressure Yes No 4. Brugada syndrome? Yes No Li] 2 Long QT syndrome? If Yes to ether, please give details in section 9, page 7 and eniclose relevant hospital notes. Cees All questions must be answered. If resting blood pressure is 180 mmvHg systolic or more ‘and/or 100mm/Hg diastolic or more, please take a further 2 readings at least 5 minutes apart and record the best Of the 3 readings in the box provided. 1, Please record today’s best. fy resting blood pressure reading, |_/ _| 2. |s the applicant on anti-hypertensive treatment? Yes No Yes, please provide three previous readings [| [ | with dates if available, i / / 3, Is there a history of malignant hypertension? Yes. No I1'Yes, please give details in section 9, page 7 (including date of diagnosis and any treatment ete) emer eased Have any cardiac investigations been undertaken or planned? If No, go to section 4, Psychiatric illness: I Yes, please answer questions 1 to 7. 41. Is there a history ofthe folowing: (a) left bundle branch block (LBBB)? { (0) right bundle branch block (RBBB)? Ifyes to (aor (b), please provide relevant report(s)or comment in section 9, page 7. 2 Note: f Yes to questions 2to 6, please give dates in the boxes Provided, give details in section 9, page 7 and provide relovant reports. Has an exercise ECG been undertaken Yes No (or planned)? 10 Has an echocardiogram been undertaken Yes No (or planned)? OU O UO O (@) If undertaken, is or was the left ejection fraction greater than or equal to 40%? Has a coronary angiogram been undertaken Yes No (or planned)? Oo Has @ 24 hour ECG tape been undertaken Yes No (or planned)? Ctl Has a loop recorder been implanted Yes No (or planned)? 1 Has @ myocardial perfusion scan, stress Yes No echo study or cardiac MR been undertaken) ) (or planned)? (| (RBGSeneroten ness Is there a history or evidence of psychiatic Yes. No illness within the last 3 years? oO IfNo, go to section 5, Substance misu IF Yee, please ansvier all questions below. 4. Sianificant psychiatric dsorder within the Yes. No past 6 months? If Yes, please confim condition.) [| 2. Psychosis or hypomania/mania within the Yes No past 12 months, including psychotic depression? |] || 3. (@) Dementia or cognitive impairment? Yes No (©) Are there concerns which have resuited |_| |_| in ongoing investigations for such possible diagnoses? La] Pe Ry |s there a history of drug/alcohol misuse Yes No or aapendnest oi Ifo, 99 to section 6, Slop dlsorders Me, te aver ai quater os 1. ete aston of aleotol dependence Yes No sepa! yon oo (@ Isit controled? nn (b) Has the applicant undergone an alcohol oo Sieaton pat wee gwaesaes [| [| | | | 2 Paratnt acchol muse nthe past years? JSS NS (9 let conrotoa? 1H 9. Uitte gs ere sacs rm Yon No ‘of prescription medication in the last 6 years? (@) If Yes, the type of substance misused? an Cit) fio LEE TTT) (b) Is itcontrolled? (6) Has the applicant undertaken an opiate treatment programme? It Yes, give date started Applicant's full name owe onn) | TT 11 |CS Tle 1 Tamu Applicant's full name Is there a history or evidence of Obstructive Yes No ‘Sleep Apnoea Syndrome or any other medical] [~] condition causing excessive sleepiness? If No, go to section 7, Other medical conditions. IF Yes, please give diagnosis and answer all questions below. 4) If Obstructive Steep Apnoea Syndrome, please indicate the severity: Mila (AHI <15) Moderate (AHI 15-29) |_| Severe (AHI >29) Not known if another measurement other than AHI is used, it ‘must be one that is recognised in clinical practice ‘8 equivalent to AHI, DVLA does not preseribe different measurements as this is a clinical issue. Please give deta in section 9 page 7, Further details. ») Please answer questions () to (vi) forall sleep conditions @ daoctctared: [TT TT | veo no (@ sit controled successtally? iE (i) IF ¥es, please state treatment. Yes No (0) Is applicant compliant with treatment?) /) () Please state period of control: = a (vi Date of last review. Teed Yes No Is there a history or evidence of narcolepsy? Oo Is there currently any functional impairment Yes No that is likely to affect control of the vehicle? [| [| Js there a history of bronchogenic carcinoma Yes No or other malignant tumour witha significant lability to metastasise cerebrally? OO Is there any iliness that may cause significant Yes No fatigue or cachoxa tat afects sate atvieg? [] L_] 1s the applicant profoundly deat? oO 5 If Yes, is the applicant able to communicate in the event of an emergency by speech YS No or by using a device, e.g. @texiphone? |_| 6. Does the applicant have a history Yes No of Wer disease of any origin? OO Yes, i this the result of alcohol misuse? oOo IF Yes, please give detain section 9, page 7 7. ts there a histor of renal faire? Yes No If Yes, please give details in section 9, OO age. {8 Does the applicant have severe symptomatic Yes respiratory disease causing chronic hypoxia? |_| |_| Yes No Does any medication currently taken cause the applicant side effects that could affect OU sate driving? If Yes, please fil in section 8, Medication and give symptoms in section 9, page 7. 10. Does the applicant have any other medical Yes No Condition that could affect safe driving? 1O If Yes, please provide details in section 9, page 7. Please provide detals of all current medication including eye drops (continue on a separate sheet if necessary) a Reason for taking: ‘Approximate date started (f known): ee eemen| Reason for taking Approximate date started if known): l nee meen Reason for taking Approximate date started if known} a Reason for taking Approximate date started if known} a Reason for taking ‘Approximate date started (f known} Date of birthPea ue cy ae eo Please send us copies of relevant hospital notes. Do not send any notes not related to fitness to dive. Use the space below to provide any additional information Please provide details of type of specialists or consultants, including address. Consultant in Reason for attendance Name Address Date of last appointment: ‘Consultant in Reason for attendance Name Address Date of last appointment: | more consultants seen give details on a separate sheet. Rees ETE Clie) ero ‘Tobe filed in by the doctor carrying out the examination Please make sure al sections of the form have been filed in. ‘The form willbe returned to you if you do not do this. | confirm that this report was fil in by me at examination land I have taken the applicant's history into account. | also confirm that | am currently GMC registered and licensed to practise in the UK or | am a doctor who is medically registered within the EU, if the report was filled in outside the UK. Applicant's full name Signature of examining doctor Date of signature Doctor's stamp Date of birthThe applicant must fill in this page Applicant’s declaration ‘You must fill in this section and must not alter it in any way. Please read the following important information carefully then sign to confirm the staternents below. Important information about fitness to drive ‘As part of the investigation into your fitness to drive, we (DVLA) may require you to have a medical examination and/or some form of practical assessment. If we do, the individuals involved in ‘these will need your background medical details, to carry out an appropriate assessment. ‘These individuals may include doctors, orthoptists at eye clinics or paramedical staff at a driving assessment centre. We will only share information relevant to the medical assessment of your fitness. to drive, ‘A\so, where the circumstances of your case appear to suggest the need for this, the relevant medical information may need to be considered by one or more of the members of the Secretary of State's Honorary Medical Advisory Panels. The membership of these Panels conforms strictly to the principle of confidentiality. For information about how we process your data, your rights and who to contact, see our privacy Notice at www.gov.uk/dvla/privacy-policy Declaration | authorise my doctor, specialist or appropriate heaithcare professional to disclose medical information or reports about my health condition to the DVLA, on behaif of the Secretary of State for ‘Transport, that is relevant to my fitness to drive. | understand that the doctor that I authorise, may pass this authorisation to another registered healthcare professional, who will be able to provide information about my medical condition that is relevant to my fitness to drive. | understand that the Secretary of State may disclose ‘such relevant medical information as is necessary to the investigation of my fitness to drive to doctors and other healthcare professionals such as orthoptists, paramedical staff and the Secretary of State for ‘Transport’s Honorary Medical Advisory panel members. | declare that | have checked the details | have given ‘on the enclosed questionnaire and that, to the best ‘of my knowledge and belief they are correct. | understand that itis a criminal offence if| make a false declaration to obtain a driving licence and can lead to prosecution, Name Signature Date | authorise the Secretary of State to correspond with medical professionals via electronic channels (fax and/or email) Yes No Checklist + Have you signed and dated the declaration? + Have you checked that the optician, optometrist or doctor has filled in all parts of the report and all relevant hospital notes have been enclosed? Yes Yes Important This report is valid for 4 months from the date the doctor, optician or optometrist signs it. Please return it together with your application form.