Senior Assessment Form"*" indicates required fieldsPhoneThis field is for validation purposes and should be left unchanged.Name of primary contact for communication regarding this assessment* First Last Name of the person that will be taking the assessment* First Last Contact Email* Contact Phone*Contact Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Person taking assessment date of birth*MonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person taking assessment age*Does the person taking the assessment have a valid drivers licence* Yes NoIs the license suspended?* Yes NoAny recent collisions?* Yes NoDate of CollisionMonthMonth123456789101112DayDay12345678910111213141516171819202122232425262728293031YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Was the person taking the assessment issued a ticket or warning? Yes NoDescription of CollisionReason for assessment*Examples might include concerned children, doctors recommendation, developed fear of driving, etc.Primary objective for the senior driving assessment?*Medical SectionThese questions help us prepare for the senior assessment and ensure we address the individuals specific needs.Was the driving assessment prescribed by a medical professional?* Yes NoHow will the prescription order be delivered?EmailFaxIn PersonWhat is the emotional state of the person taking the driving assessment?*Physical or Cognitive Issues*Does the person taking the driving assessment live with medical, physical, emotional, behavioral or have a specific diagnosis including but not limited to Alzheimer’s, Dementia, brain injury, brain tumor, stroke, Parkinson’s, epilepsy, visual or auditory processing issues? Yes NoDate of Diagnosis Please describe physical and/or cognative issuesIs the assessment taker recieving any treatments for their diagnosis?* Yes NoIs the assessment taker on any medications?* Yes NoPlease list medications belowEyesight*Please select below with 5 being excellent and 1 being very poor.54321Does the assessment taker use any of the following while driving* Contact Lenses Glasses OtherHearing*Please select below with 5 being excellent and 1 being very poor.54321Does the assessment taker wear hearing aids?* Yes NoHas the assessment taker had a recent surgery?* Yes NoPlease explain surgeryIf the client had brain surgery to remove a tumor, are there any tracking difficulties?
