CONFIDENTIAL ASSESSMENT APPLICATION
SECTION A: ABOUT YOU, GENERAL INFORMATION
Title: Mr Mrs Miss Ms Dr Other
Surname:
First Name(s):
Address:
Postcode:
In case we need to contact you or leave you a message, please tell us your;
Telephone number:
Mobile telephone number:
Email address:
Can we use this e-mail address to send you your assessment report? YES NO
Date of birth:
/Ethnic Group:
General Practitioner Name:
Telephone Number:
General Practitioner Address:
Postcode:
SECTION B: ABOUT YOU and YOUR DIAGNOSIS.
Please tell us about your Medical Condition, Diagnosis or Disability.
How long have you had this Medical Condition / Diagnosis or Disability?
Please describe how your medical condition affects you.
Please list any medication you take.
When and where did you last have your eyesight tested?
Please tick whether you are RIGHT or LEFT hand dominant?
What is your height? What is your weight?
Do you receive any of the following payments?Higher Rate Mobility Component. (Of DLA) YES NO
War Pensioners’ Mobility Supplement YES NO
Personal Independence Payment YES NO
SECTION C: ABOUT YOU and YOUR MOBILITY.
Do you need to use any mobility or walking aids? YES NO
If YES please give us the details, If NO please go to SECTION D.
Mobility Aid Used
/Make and Model
/Walking Aids
Manual wheelchair:
Indoor Outdoor / /Crutches
Power Chair:
Indoor Outdoor / /Rollator / wheeled walker
Scooter:
Indoor Outdoor / /Walking stick(s)
Zimmer FrameCan you walk or take a few steps? YES NO
Can you stand without help? YES NO
If you use a wheelchair, can you transfer into a vehicle without help from others?
YES NO
Are you able to load or transport your wheelchair in your vehicle without help from anyone else?
YES NO
Does someone else load it for you? YES NO
If yes please explain how they do this:SECTION D: ABOUT YOU and DRIVING (If you are applying for a PASSENGER or HOIST ASSESSMENT, please go to SECTION E)
Do you have a driving licence? YES NO
If NO please contact the Mobility Centre for advice:
Tel 01872 254920
If YES, what type of licence do you have? (Please tick)Full Provisional Revoked Surrendered
Section 88 (You have applied to DVLA to renew your licence)
What is your Driver Number?
When does your licence expire?
Was your licence issued in the UK? YES NO
If NO where was your licence issued?
Have the DVLA been informed of your medical condition?
YES NO
If yes, what date did you inform them?
Have you been advised to stop driving? YES NO
If yes, was this by (Please tick) a doctor or the DVLA
Are you currently driving YES NO If No please tell us if you:
Have never driven Have had driving lessons in the past
Are currently having driving lessons
If you used to drive but stopped, what date did you stop?
Have you had any accidents recently? YES NO
If yes, please give details.
SECTION E: ABOUT YOU and YOUR VEHICLE(S)
Do you currently have a vehicle? YES NO
If yes, what is the Make: Model:
And year of Manufacture:
What type of vehicle do you drive at present?
Manual Transmission Automatic TransmissionIs your vehicle adapted in any way YES NO
If yes, please give details:Is your vehicle on lease through Motability? YES NO
If yes, what is the renewal date?
Anything else you wish to add which may be relevant to your assessment:
Please tell us how you heard about us:
Occasionally people cancel appointments at short notice. Would you like us to tell you about last minute cancellations if it would mean an earlier appointment? YES NO
Please tell us of any dates within the next two months that you would not be able to attend for your assessment:
Do have any other special requirements (e.g. will you need accommodation in or near the assessment location?) YES NO
If yes, can you please explain your requirements?Please tell us what you hope to achieve from this assessment?
Please tell us a bit about any difficulties you are experiencing as a driver or passenger?
Has someone else suggested that you should have this assessment? YES NO
Are they paying for this assessment? YES NO
If yes, please give us their name and address.
Name:
Address:
Postcode: Telephone Number:Email address:
WHERE WOULD YOU LIKE TO HAVE YOUR ASSESSMENT? (Please tick)
· Cornwall Mobility Centre, Truro
/· Plymouth
/· Holsworthy Hospital, Holsworthy, Devon (non-DVLA referrals only)
/· Exeter
/· Echo Centre, Liskeard
/· West Cornwall Hospital, Penzance
/· Launceston General Hospital, Launceston
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CONSENT AND DECLARATION
Cornwall Mobility may need to use information about you for statistical purposes. Any information used by Cornwall Mobility will be anonymised and all information held will be treated as strictly confidential under the terms of the Data Protection Act.
Cornwall Mobility may need to contact your GP, Consultant or other healthcare professional for medical details to help us carry out your assessment and may with your consent, send a copy of your assessment report to your GP, the DVLA, Motability, your insurance company, solicitor and any other person or organisation who referred you for the assessment.
Be aware that in the case of a Driving Assessment you will be given advice and information regarding your ability to drive.
Please sign below to indicate your consent for Cornwall Mobility to carry out your assessment and to share the information about you as described above.
NAME: (Please print)SIGNATURE:
DATE:
If you are signing on behalf of the applicant please could you indicate your relationship to them e.g. relative, legal Guardian etc.?
……………………………………………………………………………………………
On occasions, Cornwall Mobility may have health professionals or Approved Driving Instructors who wish to observe an assessment process for training purposes. If you do not wish to have an observer attend your assessment, please tick the box.
Thank you for completing this application form. Please return it by post to:
Cornwall Mobility, North Buildings, Royal Cornwall Hospital
Truro, TR1 3LJ.
Or by email to:
If you have any problems completing the form or need any further information, please telephone us on
01872 254920
Or email us at
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