Post-Stroke Driving Assessment Form
Evaluate your driving readiness after a stroke. Please answer each question based on your current abilities.
How confident do you feel about your ability to drive after your stroke?
*
Very confident
Somewhat confident
Unsure
Not confident
Rate your current ability in the following areas related to driving:
*
Rows
Not at all
Somewhat
Mostly
Completely
Vision (seeing clearly)
1
2
3
4
Attention and concentration
5
6
7
8
Reaction time
9
10
11
12
Movement and coordination
13
14
15
16
Judgment and decision-making
17
18
19
20
Have you experienced any new vision problems since your stroke?
*
No
Yes, minor issues
Yes, major issues
Do you have any difficulty turning your head or moving your arms and legs while driving?
*
No difficulty
Some difficulty
Significant difficulty
How often do you feel distracted or confused while driving?
*
1
2
3
4
5
In the past month, have you had any near-misses or minor accidents while driving?
*
No
Yes, once
Yes, more than once
How would you rate your overall alertness when driving?
*
1
2
3
4
5
Are you currently taking any medications that make you feel drowsy or less alert while driving?
*
No
Yes
Not sure
Please share any additional concerns or comments about your driving readiness.
Submit Assessment
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