CAR ADAPTATION ASSESSMENT APPLICATION FORM. If you are unsure if this is the appropriate assessment, please ring to discuss.

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1 Sent/Initials... QEF Mobility Services 1 Metcalfe Avenue, Carshalton Surrey, SM5 4AW Tel: Fax: mobility@qef.org.uk achieving goals for life CAR ADAPTATION ASSESSMENT APPLICATION FORM If you are unsure if this is the appropriate assessment, please ring to discuss. PAYEE: (Please complete using CAPITALS and return to the above address) PERSONAL INFORMATION TITLE: SURNAME: FORENAME: DATE OF BIRTH: / / ADDRESS: TEL (home): TEL (mobile): POSTCODE: TEL (work): If we have to call you and you are not available may we leave a message? What is the nature of your disability/medical condition? Please give brief details: Date of onset: Do you experience any pain? Have you informed the DVLA of your disability/medical condition? Are you in receipt of the higher rate mobility component of the Disability Living Allowance? Have you been assessed by this Mobility Centre before? Please give details? If YES, what year? If NO, how did you hear of us? General practitioner/consultant: Address: Telephone: Postcode: 1 August 15

2 DRIVING EXPERIENCE AND LICENCE DETAILS (please delete as appropriate) Have you ever held a Driving Licence? Type of licence: FULL/PROVISIONAL Licence number (if known): Expiry date: Do you have any points on your licence? If yes, how many? Please note that you must include a copy of your driving record which is available from the DVSA website at If you want us to print the record, please use this link and call us with the access code (which is only valid for 72 hours). If you have any difficulty with this process please telephone for assistance Number of years driving experience? Have you driven other groups of vehicles? Eg LGV, PCV, 2 wheeled motorcycle? Please give details: IMPORTANT: in order to carry out the in-car drive on public roads you will need to have one of the following: (please indicate the one that applies to you) a) Full driving licence b) Provisional driving licence c) Provisional Disability Assessment Licence d) Section 88 cover e) Letter of authorisation to drive from the DVLA f) I do not have any of the above If you do not have a licence or it is about to expire, have you applied or re-applied to the DVLA for a licence? Please give details: PLEASE NOTE: during your assessment it may not be possible to undertake a drive on public roads, but we will use our own private track to assess your ability to control a car. Depending on the type of assessment, you may need to return to the centre for an on-road drive for a final decision regarding your driving safety. There will be an additional charge for this. INFORMATION ABOUT YOUR CURRENT DRIVING ACTIVITIES (* please delete as appropriate) Are you driving at the moment? (*) If YES, approximately how many miles a week? If NO, when did you last drive? If NO, why have you not driven for this time? Car Make: Model: Year: Automatic/manual (*) Estate/saloon/hatchback (*) Does it have any adaptations? (*) If YES, please specify: 2 August 15

3 MEDICAL INFORMATION (* please delete as appropriate) 1 Have you ever had a head injury /period of unconsciousness/brain surgery? If YES, please give date and details: 2 Have you ever had epilepsy? 3 Do you have episodes of fainting? (Other than simple attacks associated with the sight of blood or disturbing news etc) 4 Do you have dizziness or vertigo? (Exceptions as above) 5 Do you have diabetes? If YES, a) is it controlled by insulin? b) is it controlled by tablets? c) have you ever had a hypoglycaemic attack? 6 SIGHT: Do you have any defect of vision? (Other than requiring correction by spectacles) IF YOU WEAR GLASSES PLEASE BRING THEM WITH YOU 7 HEARING: Do you have any difficulty with your hearing? IF YOU WEAR HEARING AIDS PLEASE BRING THEM WITH YOU 8 MEDICATION: please give details below of any pills or medicine you take and bring a list with you 9 Have you been prescribed any medication which you do not take for any reason? FOR OFFICE USE ONLY: I confirm that I have suitable licence cover that is valid in the UK for this assessment The above medical information is correct and current Driver s name (capitals) Driver s signature Assessor s signature Date: 3 August 15

4 LIFESTYLE INFORMATION (*please delete as appropriate) Do you require assistance for: (please give details in the space provided) Personal care? Domestic tasks? Outdoor mobility? Are you working? How has your condition caused you to alter you lifestyle, employment situation or leisure activities? Can you independently transfer into and out of a car? Do you need equipment/assistance to transfer? If YES, please give details. Are you a wheelchair user? MANUAL/ELECTRIC (*) Name/type of wheelchair: Can you independently load/ unload your wheelchair into a vehicle? DECLARATION I give consent for this assessment to be carried out and for QEF Mobility Services to contact my Doctor, should it be considered necessary, for any further medical information relevant to this assessment, which will be treated in strict confidence. I understand a copy of the report may be sent to my Doctor. I understand and agree that the assessment may involve some manual handling application to enable me to access any relevant equipment, such as the static rig unit or into a car. I also agree that staff may occasionally record images during assessments to provide additional content to the written report. I accept that if I fail to attend my appointment or if I do not give at least 5 working days cancellation notice, the fee will not be refunded. There will be a 25% administration charge for all cancellations if another appointment is not required. QEF may hold information regarding your assessment under the Data Protection Act 1998, to monitor and compare any previous assessment outcomes. Signed.... Date PAYMENT : I would like to pay Mastercard/Visa/Delta/Switch * Card No: via (please tick): Expiry date: / Security No to be given when booking appointment: Office use only Cheque/Postal Order (delete as appropriate) made payable to: QEF Mobility Services. Please put your card number and address on the back of your cheque. If you are not paying for the assessment yourself, please provide details of the person/organisation who has agreed to meet the cost of the assessment. Name (person/organisation): Address: Postcode: Contact Name: Contact Tel No: 4 August 15

5 EQUAL OPPORTUNITIES DATA We are obliged to ask this information from the organisations that fund our service. You do not have to answer these questions, and if you choose not to, this will not make any difference to the service you receive. This section of the application form will be detached and the information collected will only be used for monitoring purposes in an anonymised format. Ethnic Origin: Asian Bangladeshi ( ) Asian Indian ( ) Asian Other ( ) Asian Pakistani ( ) Black African ( ) Black Caribbean ( ) Black Other ( ) Chinese ( ) Mixed Other ( ) Mixed White + Asian ( ) Mixed White + Black African Mixed ( ) Mixed White + Black Caribbean ( ) White British ( ) White Irish ( ) White Other ( ) Ethnic Other ( ) Please specify Declined to comment ( ) 5 August 15