Older driver preconsultation self-administered questionnaire on health
| Item | Yes | No |
| Changes in health status since the last medical examination for fitness to drive | ||
| Current or past medical conditions: | ||
| Eye problem, and/or wearing glasses or contact lenses | ||
| Sleep apnoea and/or other diseases leading to daytime sleepiness | ||
| Cardiac or vascular disease: high or low blood pressure, chest pain, heart attack, coronary bypass, coronary angiography, palpitations, irregular heartbeat, arrhythmia, pacemaker or defibrillator, thrombosis, embolism, aneurysm, and so on | ||
| Pulmonary disease: asthma, chronic bronchitis, emphysema, difficulty breathing | ||
| Diabetes and/or other metabolic disease | ||
| Problems with memory and/or concentration | ||
| Neurological disease: epilepsy or other seizure disorder, Parkinson's disease, stroke, paralysis, multiple sclerosis, light-headedness, fainting spells or loss of consciousness, and so on | ||
| Problems with balance and/or dizziness | ||
| Deafness | ||
| Bone or joint disease: chronic pain, osteoarthritis, rheumatism, and so on | ||
| Digestive problems: liver disorder, and so on | ||
| Kidney disease: kidney failure, dialysis, and so on | ||
| Psychological problem: depression, schizophrenia, psychosis, bipolar disorder, and so on | ||
| Alcohol problem | ||
| Psychotropic drug abuse: anxiolytics, sleeping pills, and so on | ||
| Illegal drug use: cannabis, heroin, methadone, cocaine, and so on | ||
| Injury requiring surgery and/or with after-effects | ||
| Other diseases or disabilities that may interfere with safe driving | ||
| List and dates of past hospitalisations: ______________________________________ | ||
| List and dates of past surgeries: ___________________________________________ | ||
| List of current drugs: ____________________________________________________ | ||
| Driver's licence revoked for any reason: drink-driving, drug-driving, speeding, and so on |