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Driver Evaluation Request
First & Last Name: *
Full Address: *
Phone: *
E-mail: *
Gender:	Male Female
Date of Birth:
Driver's License / Permit Number:
State (on license):
Expiration date:
Restrictions:
*** Driving History ***
What are your total years of driving experience?
Have you driven since your illness/injury?	Yes No
Have you had any accidents or violations in the last five years?	Yes No
Have you had your license suspended or taken away?	Yes No
Have you had any DWI/DUI convictions?	Yes No
If you answered YES to any of the prior 4 questions please explain here:
How often do you think you might drive?
What is the most frequent distance you plan on driving?
What is the longest distance you think you might drive?
Do you plan to drive on the freeway?	Yes No
Do you plan to drive at night?	Yes No
Do you have difficulty with glare?	Yes No
Have you had issues with contrast sensitivity?	Yes No
Do you use a GPS?	Yes No
Have you tried to get in and out of this vehicle since your injury/illness?	Yes No
If yes, how much assistance did you require?
Do You Own a Vehicle?	Yes No
- Make, Model, Year
If you do not own a vehicle, is there a certain vehicle you are hopping to obtain?
Please Describe:
Anything else we should know?
If driving from a wheelchair, what kind?
* * * Medical History * * *
Disability or/and Diagnosis (Dx):
Date of Dx onset:
Past Medical History:
Medications Currently Using (Please list how often you take each medicine.)
Have you ever had seizures?	Yes No
If so, when was the last time?
Are you currently taking medicine for seizure control?	Yes No
If so, what medication?
Spasms?
Corrective Lenses/Contacts?	None Yes For Reading For Driving
Do you have any loss of vision?(If so, please describe the extent and location)
* * * If you have had an eye or hearing exam since your illness or injury, please acquire a copy of the report prior to your evaluation * * *
Describe any problems you have using your arms and hands:
Describe any problems you have using your legs or feet:
Impediments to Driving:
How do you get around:	Walk unassisted Manual wheelchair Power wheelchiar Power scooter Walker Cane
Do you wear or use:	Glasses/contacts (for driving) Hearing aid Artificial limbs Splints Oxygen Splints Braces Shoe lifts
If you use any other type of adaptive devices, what is it?
Mobility:	Ambulatory Non-Ambulatory Short Distances Only Transfers into vehicle Transfers to Transfer Seatbase Drive from Wheelchair
Adaptive Equipment (include any additional wheelchair information):
* * * Referring Physician info * * *
Physician's Name:
Physician's Address:
Physician's Phone Number:
Physician's Fax Number:
Workers Compensation (Only if Applicable)
Insurance Plan Name:
Client Workers Comp #:
Insured Policy Group #:
Pre-authorization #:
Send Invoice to:
E-Mail:
Fax #:
* * * EMERGENCY INFORMATION * * *
Contact name:
Contact relationship:
Contact phone:
Contact address:
This form was completed by: *
I have read, and agree to comply with the 'Client Contract' posted on this website: *	I Agree