UCL HUMAN RESOURCES DIVISION
OCCUPATIONAL HEALTH SERVICE
Drivers’ Health Assessment.
Please complete the following:
Name:
Date of birth:
Job title:
Dept:
Faculty:
Please consider the questions below. If you answer YES, details will be discussed with the
Occupational Health Advisor in confidence.
Have you EVER experienced or been diagnosed with (please circle):
1. Seizures or epilepsy?
2. Dizziness, fainting or vertigo?
3. Stroke, sudden collapse or blackouts?
4. Diabetes?
5. Heart problems including: Heart attack?
Heart surgery?
Angina?
Irregular heart beat?
6. High blood pressure?
7. Vision problems including: Loss of an eye?
Problems with your field of vision?
Double vision?
Eye injury?
Glaucoma?
8. Mental health issues including alcohol or drug problems?
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
YES / NO
Finally, are you currently taking any medication of any type?
YES / NO
UCL Occupational Health Service
Gower Street London WC1E 6BT
Tel: +44 (0)20 7679 7724 Fax: +44 (0) 20 7209 0256
ohadmin@ucl.ac.uk
www.ucl.ac.uk/hr/occ_health/
I declare that I have answered the questions on this form honestly and fully and that I am
not otherwise aware of any physical or mental disability which will or may affect my ability
to drive. I understand that my employer will be notified of my fitness to drive, and that my
medical information will remain confidential to OH. I agree to a copy of the outcome being
sent to Finance for insurance purposes.
Print name:
Signature:
Date:
OFFICE USE ONLY:
BP: (<180/100 mmHg)
HT:
KEYSTONE: NAD / REFER
URINALYSIS:
PULSE:
QUERIES ABOVE? Y / N
REGULAR? Y / N
WT:
BMI:
MUSCULAR-SKELETAL ISSUES?
COMMENTS:
Review: at 45 years old / in 5 years (>45 yrs old) / annually (>65 years old)
OHA:
PRINT:
UCL Occupational Health Service
Gower Street London WC1E 6BT
Tel: +44 (0)20 7679 7724 Fax: +44 (0) 20 7209 0256
ohadmin@ucl.ac.uk
www.ucl.ac.uk/hr/occ_health/
DATE: