Taxi Driver Medical Assessment Form
Use this form to assess a taxi driver’s medical fitness for duty. Please provide accurate health and work-related information.
Driver Identification and Work Context
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Employer / Company Name
Role / Position
*
Taxi Driver
Other Driving Role
Office / Admin
Other
Assessment Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Health History and Current Symptoms
Current symptoms affecting driving
None
Daytime sleepiness
Dizziness or lightheadedness
Blurred vision
Headache
Chest discomfort
Shortness of breath
Reduced concentration
Pain affecting movement
Other
Known chronic conditions relevant to driving ability
Diabetes
High blood pressure
Heart condition
Sleep apnea
Epilepsy or seizures
Stroke or TIA history
Vision impairment
Hearing impairment
Neurological condition
Mental health condition
Other
Current medications that may affect alertness
Recent illness or injury in the last 12 months
*
Yes
No
If yes, please describe the illness or injury
Vision problems
*
No vision problems
Mild difficulty
Moderate difficulty
Significant difficulty
Under specialist care
Hearing problems
*
No hearing problems
Mild difficulty
Moderate difficulty
Significant difficulty
Under specialist care
Episodes of dizziness, fainting, seizures, chest pain, or shortness of breath
*
No
Yes
If yes, please provide details
Medical Fitness Assessment
Vision
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Hearing
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Alertness
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Mobility, Reaction Time, and Stamina
*
Poor
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Poor, 10 is Excellent
Examiner Observations
*
Rows
Pass
Concern
Blood pressure if measured
1
2
General appearance
3
4
Mobility
5
6
Balance
7
8
Concentration
9
10
Overall Fitness Outcome
*
Please Select
Fit for duty
Fit with restrictions
Unfit pending review
Examiner Notes and Recommended Restrictions
Declarations and Examiner Sign-off
Applicant Signature
*
Date Signed
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Assessment
Submit Assessment
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