Occupational Therapy Driver Assessment Questionnaire
Please complete this questionnaire to help assess your readiness for driving. Your honest responses will support a thorough occupational therapy evaluation.
Full Name
*
First Name
Last Name
How would you rate your overall confidence in your driving ability?
*
1
2
3
4
5
Do you currently experience any of the following while driving? (Select all that apply)
*
Difficulty seeing road signs or signals
Trouble maintaining lane position
Problems with reaction time
Becoming easily distracted
Physical discomfort while driving
None of the above
Have you had any driving incidents (e.g., near misses, accidents, getting lost) in the past 12 months?
*
No
Yes, minor incidents only
Yes, major incident(s)
Do you use any assistive devices or vehicle modifications when driving?
*
No
Yes, occasionally
Yes, always
Are you currently taking any medications that might affect your alertness or ability to drive?
*
No
Yes, but they do not affect my driving
Yes, and I have noticed effects while driving
How often do you drive in the following situations?
*
Rows
Never
Rarely
Sometimes
Often
Driving at night
1
2
3
4
Driving in heavy traffic
5
6
7
8
Driving in unfamiliar areas
9
10
11
12
Driving in bad weather
13
14
15
16
Do you ever avoid driving in certain conditions or situations? (Select all that apply)
*
At night
In bad weather
On highways
In unfamiliar areas
I do not avoid any conditions
How comfortable do you feel when driving alone?
*
1
2
3
4
5
Is there anything else you would like to share about your driving experience or concerns?
Submit Assessment
Should be Empty: