Assessing Fitness to Drive - BiOptic Driving Network

ASSESSING FITNESS TO DRIVE REPORT FORMMEDICAL CONDITION REPORT FORMTo: [Insert the address of your local driver licensing authority – see page 74]PLEASE PHOTOCOPY THIS FORM AS REQUIREDProfessional OpinionI have examined the patient whose name, address and date of birth are set out below.I consider that the patient:■ does not meet the standards in Assessing Fitness to Drive and should not drive■ does not meet the standards in Assessing Fitness to Drive, but should beconsidered for a licence subject to the following restriction:Licence Restriction:Medical Standard Not Met:Chapter Heading:Condition:The patient ■ is ■ is not aware that I have forwarded this report.I have been treating this patient for yearsPatient Details [Please Print]Surname Mr/ Mrs/ MsGiven NamesFull AddressDate of Birth | | Licence No.Health Professional Details [Please Print]Reporting Professionals NameProfessional’s AddressTelephone ( ) Date of ExaminationSignature■ My further comments on medical condition(s) affecting safe driving appear overleaf73