Elderly Driver Assessment Questionnaire Form
Use this form to assess an older driver's current driving habits, confidence, and safety-related concerns. Provide accurate answers based on the driver's current situation.
Driver and Assessment Context
Full Name
*
First Name
Middle Name
Last Name
Age
*
Phone Number or Email Address for Follow-up
*
Relationship to the Driver
*
Self
Family Member
Caregiver
Clinician
Other
Driving Status and Recent Habits
Current driving frequency
*
Daily
Several times a week
Weekly
Rarely
Stopped driving
Typical driving conditions handled
*
Daytime
Nighttime
Local roads
Highways
Bad weather
Unfamiliar routes
Recent near-misses or traffic incidents
*
No
Yes
Prefer not to say
Assessment Ratings
How confident do you feel while driving?
*
Very low
1
2
3
4
Very high
5
1 is Very low, 5 is Very high
Rate the following driving abilities
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Vision at night
1
2
3
4
Reaction time
5
6
7
8
Lane staying
9
10
11
12
Parking
13
14
15
16
Navigation
17
18
19
20
Attention to traffic signs/signals
21
22
23
24
Final Review
Recommendation Outcome
*
Continue driving as usual
Continue with restrictions
Seek a professional driving evaluation
Pause driving until reviewed
Additional Comments or Concerns
Submit
Should be Empty: