Table 1

Older driver preconsultation self-administered questionnaire on health

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
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