Fitness to Drive Medical Clinic Referral Form

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Fitness to Drive Medical Clinic
Referral Form
Send to Road Traffic Authority via Fax (02) 620 77120 or Email [email protected]
Date: _______________
Patient Details
Title: Mr Mrs
Canberra Hospital UR (if known)___________________
 Ms
Other ______
Name:_________________________________
DOB: __________________________________
Has the patient attended the Fitness to Drive
Medical Clinic before?
 Yes Date:_____________ No
Address:_______________________________
______________________________________
Interpreter required  Yes
Home phone:______________________
If yes, for which language?__________________
Mobile No: ________________________
Other language/s spoken___________________
________________________________________
Health Care Benefit Status
 Medicare No:_____________________
 Pension  Vet Affairs
 Work Cover
Marital Staus:_______________________
No
If you require an urgent appointment please state
reason i.e. licence expiring <1 month etc
________________________________________________
________________________________________________
________________________________________________
Reason for Referral Please include significant symptoms, signs and duration, degree of urgency, goals, expectations, special
issues (Remember - The appointment will be prioritised on the clinical information and investigation reports you provide)
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
Relevant past medical history
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________________
_______________________________________________________________________________________
Would you like to discuss any other details with the FTDM clinic specialist?  Yes  No
We will contact you via phone or email provided
Main Driving Requirements
 Work requirements  Shopping / banking  Social Activities  Other__________________
Driving experience
Current licence:
0-3 yrs  3-10 yrs  10-30yrs  30yrs + 
Yes

No 
 Yes
 No
Licence/Permit No. ......................................
Professional driver  Yes
(Truck, bus, taxi etc)
 No
Expiry date: ..................................................
Currently driving
Class...................Conditions..........................
Medical condition likely to deteriorate  Yes
Current Medications
Name
 N
Dose
Frequency
Allergies (including reaction)
Relevant Investigation Reports Attached
Prior to a consultation at the Fitness to Drive Medical Clinic please provide accompanying specialist reports
ie Vision – Opthalmology/Optometry, Diabetes – Endocrinology, Epilepsy - Neurology etc
Opthalmology 
Optometry

Neurology

Endocrinology 
Respiratory

Other
Cardiology
Audiology

Diabetes Education Gerontology 
___________________
Signature:_______________________________________Print________________________________
Provider no:__________________Address_________________________________________________
Contact phone number: ___________________ Email: ____________________________________
Referral Valid for 12 Months from date completed
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