Postpartum Driving Clearance Form
Use this form to review postpartum recovery status, symptoms, and functional readiness for driving clearance after childbirth.
Patient & Postpartum Background
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Preferred Contact Information
*
Delivery Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Delivery
*
Vaginal
Cesarean
Assisted
Other
Weeks Postpartum
*
Are you the patient requesting driving clearance?
*
Yes
No
Primary Clinician or Clinic Name
Recovery Status & Symptoms
Pain level
*
No pain
1
2
3
4
5
6
7
8
9
Worst pain
10
1 is No pain, 10 is Worst pain
Bleeding/lochia status
*
None
Light
Moderate
Heavy
Unsure
Incision or perineal healing concerns
*
No concerns
Yes, incision concerns
Yes, perineal concerns
Yes, both
Unsure
Dizziness or lightheadedness
*
No
Yes
Sometimes
Fatigue level
*
None
Mild
Moderate
Severe
Are you taking any medication that may affect driving?
*
No
Yes
Unsure
If yes, please list the medication(s) and how they may affect you
Do you have any range of motion limitations?
*
No
Yes
Sometimes
Please describe any pelvic floor discomfort or other symptoms that could impair safe driving
Functional Driving Readiness
Ability to sit comfortably for extended periods
*
Yes
No
Somewhat
Ability to safely turn torso and neck
*
Yes
No
Somewhat
Ability to brake quickly if needed
*
Yes
No
Somewhat
Ability to fasten the seat belt comfortably
*
Yes
No
Somewhat
Ability to react to sudden traffic events
*
Yes
No
Somewhat
Infant-related needs while driving
Feeding
Diaper changes
Soothing/Crying
Lifting Car Seat
Other
Restrictions or clinician notes
Attempted short drives already
*
Yes
No
Clearance Decision & Acknowledgement
Clinician Clearance Decision
*
Clear
Not Clear
Clear with Restrictions
Restrictions or Driving Recommendations
Acknowledgement
*
I understand the postpartum driving clearance decision and any restrictions provided.
Other
Clinician Signature
Submit Clearance Request
Submit Clearance Request
Should be Empty: