STR1V

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:

DDMMYYYY

Consultant details

Consultant name:

Speciality:

Department:

Hospital name:

Address:

Town:

Postcode:

Contact number:

Email (if known):

Date last seen for this condition:

DDMMYYYY

Medical questionnaire – stroke / transient ischaemic attack –

vocational

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

Question 1:

Have you had a single or multiple:

TIA

single

multiple

Stroke

single

multiple

Please provide date(s) of the most recent TIA/stroke

DDMMYYYY, DDMMYYYY, DDMMYYYY

Question 2:

One month after the event(s), are there any residual problems?

yes

no

a) Do you have cognitive, co-ordination, memory or understanding issues?

yes

no

b) Do you have limb weakness or sensory loss?

yes

no

c) Do you have vision problems?

yes

no

If yes, please indicate all that apply:

visual field loss

yes

no

visual inattention (as diagnosed by your consultant, not visual field loss)

yes

no

double vision

yes

no

If yes, how is your double vision controlled?

Patch/Prism/Frosted glasses or lenses

Glasses with Prism

Other

Not controlled

Question 3:

Please give details all the medication you take, including eye drops.

Please provide medication, dosage and reason for taking.

a) Does your medication make you drowsy or confused when driving?

yes

no

Question 4:

Are you able to walk at a brisk pace for 9 minutes?

yes

no

If no, please give the reason why:

Question 5:

Have you needed rehabilitation?

(for example, physiotherapy, speech therapy or occupational therapy)

yes

no

Question 6:

Have your doctors expressed any concerns about your fitness to drive?

yes

no

Question 7:

Have you ever had any form of seizure(s) or epileptic attack(s)?

yes

no (if no, go to Question 11)

Epileptic seizures are variably described and involve fits, convulsions or seizures.

Epilepsy may also occur only as auras, strange feelings or taste, absences or blank spells, limb jerking or twitching.

Epileptic seizures may occur when asleep or when awake.

Question 8:

First ever seizure, please provide the date of the seizure

DDMMYYYY

If you have had more than 1 seizure ever or diagnosed with epilepsy, please answer the following:

Question 9:

Have you ever had 2 or more seizures in a 5 year period?

yes

no

a) First awake seizure

DDMMYYYYY

b) First sleep seizure

DDMMYYYY

c) Last 2 awake seizures

DDMMYYYY,

DDMMYYYY

d) Last 2 sleep seizures

DDMMYYYY,

DDMMYYYY

e) If you have had both awake and sleep seizures, please give the date of the first sleep seizure after the last awake seizure.

DDMMYYYY

f) Have your seizures ever affected your level of consciousness?

yes (if yes, go to Q9g)

no (if no, go to Q10)

g) Would your seizures have ever caused difficulty controlling a vehicle?

yes

no

Question 10:

If you have been advised by a doctor that your seizure was a provoked or an acute symptomatic seizure, please provide full details of the circumstances of the seizure and the provoking factor.

Epilepsy Declaration

This declaration needs to be signed if you have had a diagnosis of

epilepsy or had more than one seizure.

I agree to:

follow the advice of my doctor(s) about treatment for this condition

attend, where necessary, appointments to monitor my condition

inform DVLA should I experience any further attacks

Signed:

Date: DDMMYYYY

Question 11:

Have you had an on-road driving assessment?

yes

no

If yes, please provide a copy and date of the driving assessment report

DDMMYYYY

Question 12:

Do you need to drive a Group 1 vehicle fitted with special controls or automatic controls?

yes

no

a) Do you need to drive a Group 2 vehicle fitted with special controls or automatic controls?

yes

no

If you answered no to Q12 or Q12a you do not need to answer Q12b and Q12c

b) Have you told us before that you need special controls or automatic transmission?

yes

no

c) Since your last licence was issued, have you had any additional controls fitted to your vehicle?

yes

no

d) Select any modifications that you need to drive a car:

Modified transmission (10)

Modified clutch (15)

Modified braking system (20)

Modified accelerator (25)

Pedal adaptions and pedal safeguards (31)

Combined service brake and accelerator systems (32)

Combined service brake, accelerator and steering systems (33)

Modified control layouts (35)

Modified steering (40)

Modified rear view mirror (42)

Modified driver seat (43)

e) Select any modifications that you need to drive a motorcycle, moped or tricycle

Single operated brake (44.01)

Adapted front wheel brake (44.02)

Adapted rear wheel brake (44.03)

Adjusted accelerator (44.04)

Adjusted manual transmission and clutch (44.05)

Adjusted rear view mirror (44.06)

Adjusted commands – light, indictors, etc (44.07)

Seat height – allows the driver to have 2 feet on the surface at once and balance the wheel when stopping/standing (44.08)

Adapted foot-rest (44.11)

Adapted hand grip (44.12)

Motorcycle with sidecar only (45)

f) Select any modifications that you need to drive a lorry or bus:

Modified transmission (10)

Modified clutch (15)

Modified braking system (20)

Modified accelerator (25)

Pedal adaptions and pedal safeguards (31)

Combined service brake and accelerator systems (32)

Combined service brake, accelerator and steering systems (33)

Modified control layouts (35)

Modified steering (40)

Modified rear view mirror (42)

Modified driver seat (43)

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

If you would like to be contacted about your application by email or text message (SMS) by a healthcare professional acting on behalf of DVLA, please let us know below. If not you’ll be contacted by post.

I authorise a healthcare professional to contact me by:

email – yes or no

text messages (SMS) – yes or no

Note: there will be a delay with your case if you do not give us all the information we need, including the full name, address and telephone number of your healthcare professional.

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

By email: eftd@dvla.gov.uk

Keep up to date with our latest news and services: www.gov.uk/dvla