Long-haul Driver Fitness Health Assessment Form
Please complete this assessment to help ensure you are fit and ready for long-haul driving. Answer each question as accurately as possible.
Driver Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your overall physical health today?
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
How many hours of sleep did you get in the past 24 hours?
*
Less than 4 hours
4-6 hours
6-8 hours
More than 8 hours
How alert and focused do you feel right now?
*
Very drowsy
1
2
3
4
Fully alert
5
1 is Very drowsy, 5 is Fully alert
Have you experienced any illness or injury in the past week?
*
No
Minor illness/injury
Moderate illness/injury
Serious illness/injury
Are you currently taking any medication that could affect your ability to drive?
*
No
Yes, prescription medication
Yes, over-the-counter medication
Are you experiencing any pain or physical discomfort?
*
No
Mild discomfort
Moderate discomfort
Severe discomfort
How would you rate your current mental/emotional state?
*
Very stressed
1
2
3
4
Calm and focused
5
1 is Very stressed, 5 is Calm and focused
Have you consumed any alcohol or recreational substances in the past 24 hours?
*
No
Yes, alcohol
Yes, recreational substances
Do you feel fully fit and ready to begin your long-haul driving assignment?
*
Yes, fully fit and ready
Mostly ready, minor concerns
Not ready, significant concerns
Submit Assessment
Should be Empty: