STROUD DISTRICT COUNCIL
MEDICAL REPORT
On person proposing to drive a Hackney Carriage or
Private Hire Vehicle
(A)
What you have to do.
1.
Complete Section 8 on page 6 in the presence of the examining doctor. Also provide
him with proof of your identity. Passport, drivers licence or drivers badge etc.
2.
If you have doubts about your ability to meet the medical standards, consult your
doctor BEFORE you arrange for this form to be completed. You will be charged by
your doctor for him completing this form and examining you. Stroud District Council
has no responsibility for the payment of medical fees and any fee paid by you is not
recoverable.
3.
Please read the notes below - 'MEDICAL STANDARDS FOR HACKNEY CARRIAGE
AND PRIVATE HIRE DRIVERS'.
4.
This medical report must accompany any licence application where a medical report
has been requested, or is required by the Licence conditions.
(B)
What the Doctor has to do.
1.
Complete sections 1 - 7 of this report having established the correct identity of the
person to be examined. The examination should be conducted consistent with the
latest editions of the DVLA publication "For Medical Practitioners - at a Glance Guide
for Current Medical Standards of Fitness to Drive" and the Medical Commission on
Accident Prevention’s publication "Medical Aspects of Fitness to Drive".
Stroud District Council considers hackney carriage and private hire drivers to be
group 2 occupational drivers as defined in the above publications.
2.
Applicants who may be asymptomatic at the time of the examination should be
advised that, if in future symptoms of a medical condition develop likely to effect safe
driving and a hackney carriage or private hire licence is held, the Licensing Officer at
Stroud District Council should be informed immediately.
(C)
Medical standards for Hackney Carriage or Private Hire Drivers
1.
Epilepsy/Seizure - an applicant must NOT "have a liability to epileptic seizures". If
he/she does have such a liability the Council must refuse or
revoke the licence.
2.
Diabetes -
the group 2 standard precludes the licensing of drivers with
insulin treated diabetes. However, exceptional arrangements
do exist for drivers with insulin treated diabetes, who can meet
a series of ‘medical criteria’ to obtain a licence to drive
category C1 vehicles. The Council has adopted to apply the
C1 standards to hackney and private hire drivers.
3.
Eyesight -
all drivers, for whatever category of vehicle, must be able to read
in good daylight a number plate at 20.5 metres (67 feet), and, if
glasses or contact lenses are required to do so, these must be
worn while driving. In addition:(i)
an applicant who has not held a goods vehicle or bus
licence before must by law have both
* visual acuity of at least 6/9 in the better eye; and
* visual acuity of at least 6/12 in the other eye. He/she
must also
* have satisfactory uncorrected visual acuity.
Any
applicant who has uncorrected acuity of less than 3/60
in both eyes will not be able to meet the required
standard. A driver who has an uncorrected acuity of
less than 3/60 in only one eye may be able to meet the
required standard.
(ii)
an applicant or licence holder who has held an Hackney
Carriage/Private Hire licence before 1st March 1992 but
who does not meet the standard in (i) above may still
qualify for a licence.
Where medical considerations include a relevant date(s) Stroud District Council will make
enquiries to establish the licensing position of all applicants at the date(s) in question.
An applicant or licence holder failing to meet the epilepsy, diabetes or eyesight
regulations must be refused in law.
4.
An applicant or licence holder must convey blind or hearing dogs unless there is a
medical reason for not doing so and an exemption certificate is granted by the
Council.
5.
In addition to those medical conditions covered by law, an applicant or licence
holder is likely to be refused if he/she is unable to meet the national
recommended guidelines in cases of:*
within 3 months of myocardial infarction, any episode of unstable angina, CABG
or coronary angioplasty
*
a significant disturbance of cardiac rhythm occurring within the past 5 years
unless special criteria are met
*
suffering from or being treated for angina or heart failure
*
established hypertension where the BP is persistently 180 systolic or over or 100
diastolic or over
*
a stroke, TIA or unexplained loss or consciousness within the past 5 years
*
Meniere's and other diseases causing disabling vertigo, within the past 2 years
*
severe head injury with serious continuing after effects, or major brain surgery
*
Parkinson's disease, multiple sclerosis or other "chronic" neurological disorders
likely to affect limb power and co-ordination
*
being treated for or suffering a psychotic or schizophrenic illness in the past 3
years, or suffering from dementia
*
alcohol dependency or continued misuse, or illicit drug or substance dependency
or use in the past 3 years
*
serious difficulty in communicating by telephone in an emergency
*
insuperable diplopia, pathological visual field defect or loss of normal binocular
field of vision
*
any other serious medical condition which may cause problems for road safety
and Hackney Carriage or Private Hire driving.
MEDICAL EXAMINATION Application for Hackney Carriage or Private Hire Driver's
Licence
to be completed by the Doctor taking into account the criteria
for Group 2 vocational drivers as set out in the latest editions
of:
DVLA publication "For Medical Practitioners - at a Glance
Guide for Current Medical Standards of Fitness to Drive"
Medical Commission on Accident Prevention’s publication
"Medical Aspects of Fitness to Drive".
(see accompanying notes and section 7 of this form).
Please answer all questions
________________________________________________________________________
Section 1 Vision (Please see EYESIGHT NOTES 3(i) to 3(ii) on page 2)
_________________________________________________________________________
(a)
Is the visual acuity as measured by the Snellen chart at
least 6/9 in the better eye and at least 6/12 in the other?
(b)
If corrective lenses have to be worn to achieve this
standard,
(i) is the UNCORRECTED acuity at least 3/60 in the
LEFT eye?
(ii) is the UNCORRECTED acuity at least 3/60 in the
RIGHT eye?
Yes
No
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(3/60 being the ability to read the top line of the
Snellen Chart at 6 metres)
(c)
Please state all the visual acuities for all applicants measured:UNCORRECTED
Left
(d)
Right
CORRECTED (if applicable)
Left
Right
If there is NO degree of vision whatsoever in one eye, on what date did the applicant
become monocular or develop sight in one eye only?
_______________________________________
(e)
Is there documented evidence of a pathological field
defect - e.g. hemianopia, scotoma or quadrantanopia?
(f)
Is there full binocular field of vision on confrontation?
Yes
No
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(g) Is there uncontrolled diplopia?
_________________________________________________________________________
Section 2 Nervous System
_________________________________________________________________________
Yes
No
(a)
Has the applicant a 'liability to epileptic seizures'?
(b)
Does the applicant suffer from epilepsy?
(c)
Is there a history of a sudden and disabling episode or
episodes of unexplained impaired consciousness
within the past 5 years?
(d)
Is there a history of stroke, TIA or vertebrobasilar
insufficiency within the past 5 years?
(e)
Is there a history of uncontrolled Meniere's disease
or other causes of sudden disabling vertigo within
the last 2 years?
(f)
Is there evidence, with documented signs of
neurological or cognitive impairment, of multiple
sclerosis?
(g)
Is there Parkinson's Disease or other muscle or
movement disorder likely to affect vehicle control?
h)
Is there a history of brain surgery since the last
licence was issued?
(I)
Is there a history of serious head injury associated
with an intra-cerebral haematoma or compound
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depressed skull fracture since the last licence wasissued?
Note: in the case of a first application for licence please answer (h) or (I) above.(j)
Is there a history of brain tumour, either benign or
malignant, primary or secondary?
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_________________________________________________________________________
Section 3 Diabetes Mellitus
_________________________________________________________________________
(a)
Does the applicant have diabetes mellitus? If
'Yes' please answer the following questions.
If 'No' proceed to Section 4.
(b)
Is the diabetes managed by:(i)
insulin? If 'Yes', date started on insulin?
(ii)
oral hypoglycaemic agents and diet?
(iii)
diet only?
(c)
Is the diabetic control generally satisfactory?
(d)
Is there evidence of:
(i)
loss of visual field?
(ii)
severe peripheral neuropathy?
(iii)
significant impairment of limb function or joint
position sense?
(iv)
uncontrolled episodes of hypoglycaemia?
(v)
complete loss of warning symptoms of
hypoglycaemia?
Yes
No
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_________________________________________________________________________
Section 4 Psychiatric illness
_________________________________________________________________________
Yes
No
(a)
Has the applicant suffered or required treatment for
a psychotic illness in the past 3 years?
(b)
Has the applicant required treatment for a
psychoneurotic disorder with psychotropic medication
within the past 6 months
If 'Yes',
(i) does the medication cause side
effects likely to affect driving ability?
(ii) is the condition stable or resolved?
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(c)
Is there confirmed evidence of dementia?
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(d)
In the past 3 years:-
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(i)
is there a history of continued alcohol abuse
or alcohol dependency?
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(ii)
is there a history of illicit drug or substance
use or dependency?
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If 'Yes' to either (i) or (ii) please give dates/
details of alcohol intake or type of illicit drug,
treatment and compliance with advice.
___________________________________
___________________________________
_________________________________________________________________________
Section 5 General
_________________________________________________________________________
(a)
Has the applicant a significant disability of the spine
or limbs which is likely to interfere with the
efficient discharge of his/her duties as a vocational
driver?
Yes
No
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(b)
Is there a history within the past two years of
bronchogenic or other malignant tumour with a
significant liability to metastasise cerebrally?
(i)
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If 'Yes', please give dates and disgnosis
and state whether there is current
evidence of dissemination
_____________________________________
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(c)
Is there serious difficulty preventing adequate
communication by telephone in an emergency?
(d)
Is there any medical reason why this person should not be obliged to carry either guide
dogs or hearing dogs in his/her licensed vehicle
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_________________________________________________________________________
Section 6 Cardiac
_________________________________________________________________________
(a)
Coronary artery disease
Yes
No
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Is there a history, or evidence, of:
(i)
angina pectoris or heart failure (whether or not
maintained symptom free by the use of
medication)?
(ii)
myocardial infarction/any episode of unstable
angina?
(iii)
coronary artery by pass graft (CABG)/coronary
angioplasty?
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Yes
No
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If 'Yes' to (i), (ii) or (iii) please give details/dates
______________________________________
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(iv)
Has a resting ECG been performed previously?
If 'Yes', did it show pathological Q waves present
in 3 leads or more, or left bundle branch block?
Date ECG performed
________________________________________
(A sight of the ECG tracing would be most helpful)
Please note that an ECG does not need to be
undertaken for this examination
(b)
Other vascular disorders
Is there a history, or evidence, of:
(c)
(i)
aortic aneurysm, thoracic or abdominal, with a
transverse diameter of 5cm or more (whether
or not it has been repaired)?
(ii)
confirmed symptomatic peripheral arterial
disease?
(iii)
any other significant vascular disorder (ie.
Marfans)?
Cardiac arrhythmia and heart block
Is there a history, or evidence, of:
(i)
significant disturbance of cardiac rhythm within
the past 5 years?
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Yes
No
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If 'Yes', please give details
_______________________________________
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(ii)
(d)
(e)
Blood pressure
(i)
Is the casual blood pressure reading (to the
nearest 5mm mercury) greater than 200 systolic
or over or 110 diastolic or over?
(ii)
Is there a history, or evidence, of established
hypertension, with BP readings consistently
greater than 180 systolic or over, or 100 diastolic
or over?
Acquired valvular heart disease
(i)
(f)
pacemaker or cardioverter defibrillator insertion?
Is there a history, or evidence, of acquired
valvular heart disease, with or without heart valve replacement?
Other cardiac conditions
(i)
Is there a history, or evidence, or established
cardiomyopathy, heart or lung transplant,
cardiac surgery other than above, or significant
congenital heart disorder?
________________________________________________________________________
Section 7 Statement by Medical Practitioner
(to be completed by the Doctor carrying out the examination)
_________________________________________________________________________
I consider that the applicant:
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Doctors Initials
*meets
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*does not meet
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the criteria for a Group 2 vocational driver's licence as set out in the latest editions of the
DVLA publication "For Medical Practitioners - at a Glance Guide for Current Medical
Standards of Fitness to Drive" and the Medical Commission on Accident Prevention's
publication "Medical Aspects of Fitness to Drive".
*please tick and initial whichever is applicable
Doctors Name:___________________________________
SURGERY STAMP
Doctors Address: _________________________________
_________________________________
__________________________________
Tel:
__________________________________
Signature (of Medical Practitioner) ______________________________ Date: __________
_________________________________________________________________________
Section 8 Applicant Details (to be completed by the applicant in the presence
of the Medical Practitioner carrying out the examination)
_________________________________________________________________________
About You
Your Name:
____________________________________
Date of Birth
Address:
____________________________________
______________________
____________________________________
Home Phone No.
____________________________________
______________________
____________________________________
Work/Daytime No.
______________________
About your GP/Group Practice
About your Consultant/Specialist
(If applicable)
GP/Group Name
________________________________
Cons. Name
____________________________
Address ________________________________
Address ____________________
________________________________
____________________________
________________________________
____________________________
________________________________
Tel: _________________________
Tel:
Date last seen ________________
____________________________
_________________________________________________________________________
Declaration and Authorisation (completed by applicant)
(If you have knowingly given false information in this examination you are liable to
Prosecution)
Consent and Declaration This section MUST be completed and must NOT be altered in
any way
Please sign the statement below:
I declare that I have checked the details I have given and that to the best of my knowledge
they are correct.
If a medical condition is declared I authorise my Doctor(s) and Specialist(s) to release
reports to Stroud District Council about my medical condition.
Signature ________________________________
Date ________________________
Please remember to sign and date this form
MEDICAL IN CONFIDENCE
Medical/CS/Lic