MEDICAL REPORT on an applicant for a Hackney Carriage/Private Hire Drivers Licence

Transcription

1 MEDICAL REPORT on an applicant for a Hackney Carriage/Private Hire Drivers Licence If this is your first application for Hackney Carriage/Private Hire Drivers Licence you must get a registered doctor to fill in this medical report. You will also need one if you are renewing your licence and you are 45 or over. After the age of 45 you will need a medical every five years and after the age of 65 a medical every year (please note that after the age of 70 the examination will be with the Council's Medical Advisor). Please ring North Wiltshire District Council s Medical Advisor on to make an appointment. You may also be required to undergo a medical report if the Council so determine. A. What you have to do 1. Fill in Section 8 on page 7 of this report in the presence of the Doctor carrying out the examination. 2. If you have any doubts about your ability to meet the medical standards, consult your Doctor BEFORE you arrange for this medical form to be completed. The Doctor may charge you for completing it. In the event of your application being refused, the fee you pay the Doctor is not refundable. North Wiltshire District Council has NO responsibility for the fee payable to the Doctor. 3. The notes below ("MEDICAL STANDARDS FOR HACKNEY CARRIAGE / PRIVATE HIRE ENTITLEMENT") may help you. B. What the Doctor has to do 1. Fill in Sections 1-7 of this report, having regard to The Medical Commission for Accident Prevention's booklet "Medical Aspects of Fitness to Drive" (2007 edition) and DVLA's "at a glance guide to the current medical standards of fitness to drive" (August 1994). If you have any questions about the applicant's fitness for this type of driving, telephone North Wiltshire District Council's Occupational Medical Advisor at Royal United Occupational Health and Safety on (01225) Applicants should be advised that, if in future, symptoms of a medical condition develop, likely to affect safe driving, and a Hackney Carriage/Private Hire Drivers licence is held the Taxi Licensing Officer at North Wiltshire District Council should be informed immediately. 1

2 C. Medical Standards for Hackney Carriage/Private Hire Drivers Entitlement Standards for Hackney Carriage/Private Hire drivers are higher than for car drivers. Specific conditions which are a bar to obtaining or holding this licence are as follows:- 1. Epiliepsy/Seizure - an applicant must NOT "have a liability to epileptic seizures". If he/she does have such a liability North Wiltshire District Council will refuse or revoke the licence. 2. Diabetes - an insulin treated diabetic may NOT obtain a licence UNLESS he/she held a licence valid at 1st April 1991 and North Wiltshire District Council knew of the insulin treatment before 1st January Eyesight - all drivers, for whatever category of vehicle, must be able to read in good daylight a number plate at 20.5 metres (67 feet), and, if glasses or contact lenses are required to do so, these must be worn while driving. In addition: i. An applicant for a Hackney Carriage/Private Hire Drivers licence must have both: - * a visual acuity of at least 6/9 in the better eye; and * a visual acuity of at least 6/12 in the other eye. He/She must also * have satisfactory uncorrected visual acuity. Any applicant who has uncorrected acuity of less than 3/60 in both eyes will not be able to meet the required standard. A driver who has an uncorrected acuity of less than 3/60 in only one eye may be able to meet the required standard and should check with North Wiltshire District Council's Medical Advisor at Royal United Occupational Health and Safety on (01225) , about the requirement. ii. An applicant or a licence holder who has held a Hackney Carriage/Private Hire Drivers licence before 1st March 1992 but who does not meet the standard in (i) above may still qualify for a licence. Information about the standard for such an applicant can be obtained from North Wiltshire District Council's Medical Advisor on (01225) An applicant or licence holder failing to meet the epilepsy, diabetes or eyesight regulations must be refused. 2

3 4. In addition to those medical conditions covered above, an applicant or licence holder is likely to be refused if he/she is unable to meet the national recommended guidelines in cases of:- within 3 months of myocardial infarction, any episode of unstable angina, CABG or coronary angioplasty a significant disturbance of cardiac rhythm occurring within the past 5 years unless special criteria are met suffering from or being treated for angina or heart failure established hypertension where the BP is persistently 180 systolic or over or 100 diastolic or over a stroke, TIA or unexplained loss of consciousness within the past 5 years Meniere's and other diseases causing disabling vertigo, within the past 2 years severe head injury with serious continuing after effects, or major brain surgery Parkinson's disease, multiple sclerosis or other "chronic" neurological disorders likely to affect limb power and co-ordination being treated for or suffering a psychotic or schizophrenic illness in the past 3 years, or suffering from dementia alcohol dependency or continued misuse, or illicit drug or substance dependency or use in the past 3 years serious difficulty in communicating by telephone in an emergency insuperable diplopia, pathological visual field defect or loss of normal binocular field of vision any other serious medical condition which may cause problems for road safety and Hackney Carriage/Private Hire vehicle driving Please return this report to:- Licensing Officer Environmental Health North Wiltshire District Council Monkton Park Chippenham Wiltshire SN15 1ER 3

4 IN CONFIDENCE MEDICAL EXAMINATION - to be completed by the Doctor Please answer all questions Please note the applicant must be currently registered with the examining Doctor's Practice Section 1 Vision (Please see EYESIGHT NOTES 3i to 3ii on page 2) a Is the visual acuity as measured by the Snellen Chart at least 6/9 in the better eye and at least 6/12 in the other? b If corrective lenses have to be worn to achieve this standard: - Is the UNCORRECTED acuity at least 3/60 in the LEFT eye? Is the UNCORRECTED acuity at least 3/60 in the RIGHT eye? (3/60 being the ability to read the top line of the Snellen Chart at 6 metres) c Please state all the visual acuities for all applicants measured:- UNCORRECTED CORRECTED (if applicable) Left Right Left Right d If there is NO degree of vision whatsoever in one eye, on what date did the applicant become monocular or develop sight in one eye only? e Is there documented evidence of a pathological field defect - e.g. hemianopia, scotoma or quadrantanopia? f Is there full binocular field of vision on confrontation? g Is there uncontrolled diplopia? Section 2 Nervous System a Has the applicant a 'liability to epileptic seizures'? b Does the applicant suffer from epilepsy? c Is there a history of a sudden and disabling episode or episodes of unexplained impaired consciousness within the past 5 years? d Is there a history of stroke, TIA or vertebrobasilar insufficiency within the past 5 years? e Is there a history of uncontrolled Meniere's disease or other causes of sudden disabling vertigo within the last 2 years? f Is there evidence, with documented signs of neurological or cognitive impairment, of multiple sclerosis? g Is there Parkinson's Disease or other muscle or movement disorder likely to affect vehicle control? h Is there a history of brain surgery since the last licence was issued? i Is there a history of serious head injury associated with an intra-cerebral haematoma or compound depressed skull fracture since the last licence was issued? (Note: In the case of a first applicant for licence please answer h or i above) j Is there a history of brain tumour, either benign or malignant, primary or secondary? 4

5 Section 3 Diabetes Mellitus a Does the applicant have diabetes mellitus? If 'Yes', please answer the following Questions. If 'No' proceed to Section 4. b Is the diabetes managed by:- i. insulin? If 'Yes', date started on insulin ii. oral hypoglycaemic agents and diet? iii. diet only? c Is the diabetic control generally satisfactory? d Is there evidence of:- i. loss of visual field? ii. severe peripheral neuropathy? iii. significant impairment of limb function or joint position sense? iv. uncontrolled episodes of hypoglycaemia? v. complete loss of warning symptoms of hypoglycaemia? Section 4 Psychiatric Illness a Has the applicant suffered or required treatment for a psychotic illness in the past 3 years? b Has the applicant required treatment for a psychoneurotic disorder with psychotropic medication within the past 6 months? If 'Yes': i. Does the medication cause side effects likely to affect driving ability? ii. Is the condition stable or resolved? c Is there confirmed evidence of dementia? d In the past 3 years:- i. Is there a history of continued alcohol abuse or alcohol dependency? ii. Is there a history of illicit drug or substance use or dependency? If 'Yes' to either i or ii please give dates/details of alcohol intake or type of illicit drug, treatment and compliance with advice Section 5 General a Has the applicant a significant disability of the spine or limbs which is likely to interefere with the efficient discharge of his/her duties as a vocational driver? b Is there a history within the past two years of bronchogenic or other malignant tumour with a significant liability to metastasise cerebrally? If 'Yes': Please give dates and diagnosis and state whether there is current evidence of dissemination 5

6 c Is there serious difficulty preventing adequate communication by telephone in an emergency? Section 6 Cardiac a Coronary artery disease Is there a history, or evidence, of: i. angina pectoris or heart failure (whether or not maintained symptom free by the use of medication)? ii. myocardial infarction/any episode of unstable angina? iii. coronary artery by pass graft (CABG)/coronary angioplasty? If 'Yes' to i, ii or iii please give details/dates iv. Has a resting ECG been performed previously? If 'Yes', did it show pathological Q waves present in 3 leads or more, or least bundle branch block? Date ECG performed. A sight of the ECG tracing would be most helpful) Please note that an ECG does not need to be undertaken for this examination b Other Vascular disorders Is there a history, or evidence, of: i. aortic aneurysm, thoracic or abdominal, with a transverse diameter of 5cm or more (whether or not it has been repaired)? ii. confirmed symptomatic peripheral arterial disease? iii. any other significant vascular disorder (i.e. Marfans)? c Cardiac arrhythmia and heart block Is there a history, or evidence, of: i. signifiant disturbance of cardiac rhythm within the past 5 years? If 'Yes', please give details ii. pacemaker or cardioverter defibrillator insertion? d Blood pressure i. Is the casual blood presure reading (to the nearest 5mm mercury) greater than 200 systolic or over or 110 diastolic or over? ii. Is there a history, or evidence, of established hypertension, with BP readings consistently greater than 180 systolic or over, or 100 diastolic or over? e Acquired valvular heart disease i. Is there a history, or evidence, of acquired valvular heart disease, with or without heart valve replacement? f Other cardiac conditions Is there a history, or evidence, of establishment cardiomyopathy, heart or lung transplant, cardiac surgery other than above, or significant congenital heart disorder? 6

7 Section 7 Medical Practitioner Details (to be completed by Doctor carrying out the examination) SURGERY STAMP Name Address Tel. No. In my opinion as a registered medical practitioner, the applicant has/has not reached the appropriate medical standard and is fit/unfit to drive a Hackney Carriage/Private Hire Vehicle Signature (of Medical Practitioner) Date Section 8 Applicant Details (to be completed by the applicant in the presence of the Medical Practitioner carrying out the examination) About You Your Name Date of Birth Address Home Phone No. Work/Daytime No About your GP/Group Practice About your Consultant/Specialist (If Applicable) GP/Group Name Cons. Name Address Address Tel Tel. Date last seen Declaration and Authorisation (completed by applicant) Consent and Declaration. This section MUST be completed and must NOT be altered in any way Please sign the statement below: I declare that I have checked the details I have given and that to the best of my knowledge they are correct. If a medical condition is declared I authorise my Doctor(s) and Specialist(s) to release reports to North Wiltshire District Council's Occupational Medical Advisor about my medical condition. Signature... Date... Please remember to sign and date this form MEDICAL IN CONFIDENCE 7