Name of primary contact for communication regarding this assessment*

Name of the person that will be taking the assessment*

Contact Email*

Contact Phone*

Contact Address*

Street Address Address Line 2 City State Zip

Person taking assessment date of birth*

Person taking assessment age*

Does the person taking the assessment have a valid drivers licence*

Yes
No

Is the license suspended?*

Yes
No

Any recent collisions?*

Yes
No

Date of Collision

Was the person taking the assessment issued a ticket or warning?

Yes
No

Description of Collision

Reason for assessment*

Examples might include concerned children, doctors recommendation, developed fear of driving, etc.

Primary objective for the senior driving assessment?*

Medical Section

These 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
No

How will the prescription order be delivered?

What 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
No

Date of Diagnosis

Please describe physical and/or cognative issues

Is the assessment taker recieving any treatments for their diagnosis?*

Yes
No

Is the assessment taker on any medications?*

Yes
No

Please list medications below

Eyesight*

Please select below with 5 being excellent and 1 being very poor.

Does the assessment taker use any of the following while driving*

Contact Lenses
Glasses
Other

Hearing*

Please select below with 5 being excellent and 1 being very poor.

Does the assessment taker wear hearing aids?*

Yes
No

Has the assessment taker had a recent surgery?*

Yes
No

Please explain surgery

If the client had brain surgery to remove a tumor, are there any tracking difficulties?

Senior Assessment Form

Medical Section

(480) 948-1648

Contact Us

Scottsdale, AZ

Glendale, AZ