diesel2
Member
Couldn't find the form anywhere on here, so I have dug one out and posted it. This is the 2016 version, I don't think it has changed since.
Questionnaire to assess your patient’s medical fitness to drive
1) In the past three years, has the ‘patient demonstrated persistent alcohol misuse? (including recurrent binge drinking) Y/N
If YES,
a) Is it controlled? Y/N
b) If YES, how long has this been controlled? Years/Months
2. Has there been alcohol dependence in the last three years? Y/N
If YES
a) Is it controlled? Y/N
b) If YES, how long has this been controlled? Years/Months
3. Please provide details of current consumption
a) Date last seen
4. As a result of alcohol misuse or dependence, has your patient required treatment or help from (tick as relevant)
a) Date of last detox treatment
b) Yourself
c) Support Group (e. g AA)
d) Other
If YES, please give details with dates:-
5. To your knowledge, has your patient ever been advised to modify his/her drinking behaviour or abstain from alcohol? Y/N
If YES, please give details with dates:-
6. Has your patient had blood taken for CDT, Gamma GT, AST, ALT and MCV?
If yes, please give details of result(s) including ranges and date(s) the test was taken.
7. Has your patient ever been diagnosed with any of the following problems associated with alcohol misuse or dependence (tick as relevant)
a) Fits
b) Withdrawal fits.
c) Memory problems or cognitive impairment
d) Liver/other G.I damage/Pancreatitis
e) Neurological damage/disorder
f) Cardiac symptoms
g) Other
If YES please give details with dates
8. Does your patient have any form of non-alcohol related liver disease, e. g. infective hepatitis (A/B/C), other?
If YES please give details with dates.
9. In the past three years has your patient demonstrated persistent drug misuse?
a) Is the misuse controlled? Y/N
b) If YES, for how long has this been controlled? Months
c) Give full details and confirm the type of drug(s).
10. In the past three years, has your patient demonstrated drug dependence? Y/N
a) Is the dependence controlled? Y/N
b) If YES, for how long has this been controlled? Months
c) Give full details and confirm the type of drug(s).
Questionnaire to assess your patient’s medical fitness to drive
1) In the past three years, has the ‘patient demonstrated persistent alcohol misuse? (including recurrent binge drinking) Y/N
If YES,
a) Is it controlled? Y/N
b) If YES, how long has this been controlled? Years/Months
2. Has there been alcohol dependence in the last three years? Y/N
If YES
a) Is it controlled? Y/N
b) If YES, how long has this been controlled? Years/Months
3. Please provide details of current consumption
a) Date last seen
4. As a result of alcohol misuse or dependence, has your patient required treatment or help from (tick as relevant)
a) Date of last detox treatment
b) Yourself
c) Support Group (e. g AA)
d) Other
If YES, please give details with dates:-
5. To your knowledge, has your patient ever been advised to modify his/her drinking behaviour or abstain from alcohol? Y/N
If YES, please give details with dates:-
6. Has your patient had blood taken for CDT, Gamma GT, AST, ALT and MCV?
If yes, please give details of result(s) including ranges and date(s) the test was taken.
7. Has your patient ever been diagnosed with any of the following problems associated with alcohol misuse or dependence (tick as relevant)
a) Fits
b) Withdrawal fits.
c) Memory problems or cognitive impairment
d) Liver/other G.I damage/Pancreatitis
e) Neurological damage/disorder
f) Cardiac symptoms
g) Other
If YES please give details with dates
8. Does your patient have any form of non-alcohol related liver disease, e. g. infective hepatitis (A/B/C), other?
If YES please give details with dates.
9. In the past three years has your patient demonstrated persistent drug misuse?
a) Is the misuse controlled? Y/N
b) If YES, for how long has this been controlled? Months
c) Give full details and confirm the type of drug(s).
10. In the past three years, has your patient demonstrated drug dependence? Y/N
a) Is the dependence controlled? Y/N
b) If YES, for how long has this been controlled? Months
c) Give full details and confirm the type of drug(s).