Senior Assessment Form 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 AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Zip Person taking assessment date of birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Person 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 CollisionMonth123456789101112Day12345678910111213141516171819202122232425262728293031Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Was the person taking the assessment issued a ticket or warning? Yes No Description 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 No How 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 No Date of Diagnosis MM slash DD slash YYYY Please describe physical and/or cognative issuesIs the assessment taker recieving any treatments for their diagnosis?* Yes No Is the assessment taker on any medications?* Yes No Please 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 Other Hearing*Please select below with 5 being excellent and 1 being very poor. 54321Does the assessment taker wear hearing aids?* Yes No Has the assessment taker had a recent surgery?* Yes No Please explain surgeryIf the client had brain surgery to remove a tumor, are there any tracking difficulties?
