VOCH1

If sending this by post, please complete this form in BLOCK CAPITAL
letters using BLACK INK.

IMPORTANT: Failure to provide full information for yourself, GP or consultant may result in your case being delayed.

Part A: About you

Current driving licence details

Title:

Full name:

Date of birth:

Address:

Postcode:

Email:

Contact number:

Change of details

If you have changed your contact information (address, name, email or contact number since we last corresponded with you, please provide the NEW details below.

Part B: Healthcare professional for your condition

GP details

GP name:

Surgery name:

Address:

Town:

Postcode:

Contact number:

Email (if known):

Date last seen for this condition:

DDMMYY

Consultant details

Consultant name:

Speciality:

Department:

Hospital name:

Address:

Town:

Postcode:

Contact number:

Email (if known):

Date last seen for this condition:

DDMMYY

When notifying DVLA of a heart condition it is important that you provide the correct name of any device you may have fitted. Providing DVLA with the wrong information can affect our decision about your driving licence.

Below is a list of the more common devices which may assist you when completing the questionnaire.

Pacemakers

A pacemaker is a small electrical device fitted in the chest or abdomen. It's used to treat some abnormal heart rhythms (arrhythmias) that can cause your heart to either beat too slowly or miss beats.

Implantable Cardioverter Defibrillator (ICD)

An ICD is placed under the skin just below the collarbone to monitor your heart rate through thin wires connecting electrodes to your heart. An ICD is a small electrical device that constantly monitors your heart rhythm through the electrodes and treats dangerous abnormal heart rhythms when they occur.

Cardiac resynchronisation therapy with a pacemaker (CRT-P)

Also known as bi-ventricular pacing. This treatment involves having a pacemaker with three leads called a bi-ventricular pacemaker. CRT-P can help your heart to pump more efficiently which can improve your symptoms. (Usually used in the treatment of heart failure).

Cardiac resynchronisation therapy with a defibrillator (CRT-D)

This treatment involves having a single device that combines a bi-ventricular (three-lead) pacemaker and an ICD. It's used for people with heart failure who might also be at risk of developing fast, life-threatening heart rhythms.

Ventricular assist device (VAD)

A VAD is a mechanical pump that helps pump blood from the heart to the rest of the body. It’s a treatment for weakened heart or heart failure. Some pumps are meant for short-term support (a few days or weeks), whilst waiting for other treatments, such as heart transplant, while others can be used for longer periods of time/long-term treatment. If the device is intended to be used for a limited period, for example, whilst waiting for heart transplant, it’s removed after the transplant or definitive treatment. Having a VAD fitted requires open-heart surgery.

Medical questionnaire – cardiac – vocational

If you are unsure of the answers, we advise you to discuss this form with your doctor.

Question 1:

Please indicate what type of heart or other cardiovascular problems you have and the date of diagnosis or treatment (indicate all that apply)

a) Angina

yes

no

Date of last attack

DDMMYY

b) Heart attack (myocardial infarction) or acute coronary syndrome

yes

no

Date of last attack

DDMMYY

c) Angioplasty or stent

yes

no

Procedure date

DDMMYY

d) Heart by-pass surgery (CABG)

yes

no

Procedure date

DDMMYY

e) Abnormal heart rhythm (arrhythmia) including atrial fibrillation

yes

no

Has the above condition caused any sudden and disabling giddiness/fainting or blackout within the last 12 months?

yes

no

If yes, please provide date of latest episode

DDMMYY

If yes, has this been controlled?

yes

no

f) Pacemaker

yes

no

Date implanted

DDMMYY

Are you now free of the symptoms that caused the device to be fitted?

yes

no

g) Cardiac Resynchronisation Therapy Pacemaker device (CRT-P) been implanted to improve heart failure?

yes

no

Date implanted

DDMMYY

If you have a pacemaker or CRT-P, proceed to the pacemaker declaration below

Pacemaker declaration

You must confirm you’ve read and understood the following information.

As a driver with a pacemaker fitted, I agree to:

attend regular pacemaker checks with my healthcare professional

follow the advice of my healthcare professional for the treatment of my heart condition

notify DVLA if I suffer any sudden attacks of disabling dizziness, fainting or blackouts

You must read and sign below to confirm you understand the following statement.

I have a pacemaker fitted and I agree to comply with the above conditions if I am issued with a car or motorcycle (group 1) and lorry or bus (group 2) driving licence.

Signature:

h) Catheter ablation

yes

no

Procedure date

DDMMYY

i) Defibrillator (ICD/CRT-D)

yes

no

Date implanted

DDMMYY

j) Peripheral arterial vascular disease (PVD)

yes

no

Date last seen

DDMMYY

k) Aortic aneurysm

yes

no

Date last seen

DDMMYY

Please confirm the most recent measurement of your aneurysm (if known)

Less than 4 cm

4 cm to 5.4 cm

5.5 cm or more

Don’t know

Has your aneurysm been repaired?

yes

no

If you have an aortic aneurysm proceed to declaration below.

Aortic aneurysm declaration

You must confirm you’ve read and understood the following information.

As a driver with an aortic aneurysm, I agree to:

attend yearly imaging checks under the care of a consultant cardiologist

follow the advice of my healthcare professional for the treatment of my heart condition

notify DVLA if I develop any other health condition which may impact my ability to drive safely

You must read and sign below to confirm you understand the following statement.

I have an aortic aneurysm and I agree to comply with the above conditions if I am issued with a car or motorcycle (group 1) and lorry or bus (group 2) driving licence.

Signature:

l) Aortic dissection

yes

no

Date last seen

DDMMYY

m) Heart failure

yes

no

Date last seen

DDMMYY

Are you suffering from symptoms that would affect safe driving? (For example, shortness of breath, chest pains or palpitations)

yes

no

n) Has a cardiac assist device (VAD) been implanted?

yes

no

Date implanted

DDMMYY

o) Hypertrophic cardiomyopathy

yes

no

Date last seen

DDMMYY

p) Other cardiomyopathies

yes (if yes, please provide details)

no

Date last seen

DDMMYY

q) Brugada syndrome

yes

no

Date last seen

DDMMYY

r) Long QT syndrome

yes

no

Date last seen

DDMMYY

s) High blood pressure (hypertension)

yes

no

Is it well controlled? (under 180 / 100 mmm/Hg)

Please confirm your latest blood pressure reading (if known)

t) Malignant hypertension

yes

no

Date last seen

DDMMYY

u) Any other heart condition(s)?

yes

no

If yes, please provide details

Question 2:

If required, would you be able to walk at a brisk pace for 9 minutes?

yes (if yes, go to Question 3)

no

a) If no, please tell us why:

Question 3:

Please tell us your current:

height

weight

Question 4:

Please indicate the type of cardiac investigations or procedures you have undergone or are waiting for, answer all that apply and provide most recent date attended:

Coronary angiography

yes

no

DDMMYY

Echocardiogram

yes

no

DDMMYY

Exercise test or treadmill test

yes

no

Do you know how long you exercised for to the nearest minute?

DDMMYY

Myocardial perfusion scan, stress echo or cardiac MRI

yes

no

DDMMYY

Other

yes

no

If other, please tell us the details:

DDMMYY

Applicant’s authorisation

You must fill in this section and must not alter it in any way. Please read the
following information carefully and sign to confirm the statements below.

Important information about fitness to drive:

As part of the investigation into your fitness to drive, we (DVLA) may
require you to have a medical examination and/or some form of practical
assessment. If we do, the individuals involved in these will need your
background medical details to carry out an appropriate assessment.

These individuals may include doctors, orthoptists at eye clinics or
paramedical staff at a driving assessment centre. We will only share
information relevant to the medical assessment of your fitness to drive.

Also, where the circumstances of your case appear to suggest the need for this, the relevant medical information may need to be considered by one or more of the members of the Secretary of State’s Honorary Medical Advisory Panels. The membership of these Panels conforms strictly to the principle
of confidentiality.

For information about how we process your data, your rights and who to contact,
see our privacy notice at www.gov.uk/dvla/privacy-policy

This section must NOT be altered in any way.

Declaration

I authorise my doctor, specialist or appropriate healthcare professional to disclose medical information or reports about my health condition to DVLA, on behalf
of the Secretary of State for Transport, that is relevant to my fitness to drive.

I understand that the doctor that I authorise, may pass this authorisation to another registered healthcare professional, who will be able to provide information about my medical condition that is relevant to my fitness to drive.

I understand that the Secretary of State may disclose such relevant medical information as is necessary to the investigation of my fitness to drive to doctors
and other healthcare professionals such as orthoptists, paramedical staff and the Secretary of State for Transport’s Honorary Medical Advisory panel members.

I declare that I have checked the details I have given on the enclosed questionnaire and that, to the best of my knowledge and belief they are correct.

“I understand that it is a criminal offence if I make a false declaration to obtain a
driving licence and can lead to prosecution.”

Name:

Signature:

Date:

I authorise the Secretary of State to correspond with medical professionals by:

email – yes or no

If you would like to be contacted about your application by email or text message (SMS), please let us know below. If not, DVLA will continue to contact you by post.

I authorise a representative of the Secretary of State to contact me by:

email – yes or no

text messages (SMS) – yes or no

Please complete and return all pages of this medical questionnaire and authorisation form. If you do not give us all the information we need including the full name, address, and telephone number of your GP/Consultant then there will be a delay with your case.

Please use the contact details below to return your completed medical questionnaire to the Drivers Medical Group

By Post:

Drivers Medical Group,

DVLA,

Swansea.

SA99 1DF

Email: eftd@dvla.gov.uk

Find out about DVLA’s online services

Go to: www.gov.uk/browse/driving