PAQ Form

Guidelines for completing this form:

The form can take around 10 minutes or more to complete.
After giving your answers, click the NEXT button on each page to continue.
To save your progress, click the Save and Resume Later link at the bottom. This will open a new page where you can either copy the link or have it sent to you in an email.
Please note: Closing the browser before completing this step will NOT save your progress.
All information provided is treated as confidential.

Start - Step 1 of 11

Personal Details

Title *

For example, Miss, Mr, Mx, Dr.

1. Name *

First

Last

2. Date of Birth

3. Email *

Confirm Email

Do you give consent for your assessment report to be sent to you electronically on the email address above?

Please note, if you have been referred to Herts Ability via the DVLA the report will be sent directly to them. You can request a copy by contacting the DVLA.

4. Landline Phone Number

5. Mobile Phone Number *

What is the best number to contact you on? *

Please list your postcode in the box below as shown on your driving licence

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Personal Details (continued)

6. What is your height?

Use Feet and Inches
Use Centimetres

Feet ( " )

Inches ( ' )

Centimetres (cm)

7. What is your weight?

Use Stones and Pounds
Use Kilograms

Stone (st)

Pounds (lb)

Kilograms

8. Did you complete this form yourself?

Please give the name and relationship of the person that completed this form on your behalf

9. What would you like to achieve during your assessment?

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Medical and Health Information

10. What is your medical condition or disability and when was it diagnosed?

11. Has your medical condition/disability changed how you complete your daily activities?

Yes
No
Not sure

If your medical condition has changed, please provide details.

12. Name, address and telephone number of GP or Specialist consultant

13. Does your Doctor believe you to be medically fit to drive?

If no, please provide details in the comments box below.

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Medical and Health Information (continued)

14. Please list the medication you take (if any)

15. Does your medication have any side effects that may affect your driving? For example, Drowsiness or Dizziness.

15.1 If you said yes, please state what side effects you experience.

16. Do you suffer from blackouts or sudden attacks of dizziness?

17. Do you have epileptic seizures? If yes, please answer Question 18.

18. When was the last date of your seizure?

19. Do you suffer from fatigue or tire very quickly?

20. Do you have any problems with cognition e.g short term memory, dividing your attention on more than one task at the same time, or concentration?

21. Do you have any learning difficulties or special educational needs?

22. Do you have any problems with reading, writing or speech?

23. Do you have any hearing problems?

24. Do you have any special requirements, e.g. medication or continence issues that we should be aware of during your visit?

25. Have you attended a Memory Clinic? If yes, what was the name of the Clinic and Doctor you were seen by?

26. Have you notified the DVLA of your medical condition or disability?

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Eyesight

27. When did you last have your eyesight tested?

28. Did the optician state your vision as being legal for driving at that time?

Yes
No
Not stated
Unsure

29. Do you wear glasses or contact lenses for driving?

30. Do you have any eyesight related conditions?

If yes, please provide details

31. Have you been diagnosed with a visual field deficit? If yes, please provide details in the comments box below

If yes, please provide details

Mobility and Physical Ability

32. Do you experience any pain? If yes, please move on to question 34. If no, move to question 35

33. Please give details of the pain you experience and where in your body

34. Do you experience any mobility difficulties? If yes, move to Question 36. If no move to question Question 41

35. Can you walk with or without a walking aid for approximately 100 metres/yards?

36. Do you use a wheelchair?

37. Can you transfer into a car without help from others?

38. If you use any equipment to assist you with transfers to and from a car, please give details below.

39. Do you have any other physical difficulties we should be aware of?

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Driving History

40. Approximately when did you last drive?

41. What type of vehicle are you used to driving?

Manual
Automatic
Both
None

42. Please state the problems you are experiencing whilst driving (if any)

43. Does anybody who knows you have any concerns about your standard of driving?

If yes, please provide details of that person.

44. Do you expect that you will require any vehicle adaptations in order to be able to physically control a motor vehicle?

Yes
No
Not sure

45. Do you have a car? If yes, please move to question 47, if no, move to question 50

46. Is your car manual or automatic?

Manual
Automatic

47. What make and model is your car?

For example, 'Volkswagon, Polo'

48. If your car has any adaptations or modifications, please list them below.

49. If you have had any road accidents and/or collisions in the last five years (including minor incidents), please give a brief description below.

50. If you are a full licence holder, please state how many years you have been driving

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Driving History (continued)

51. What type of vehicle would you like your assessment to be conducted in?

Manual
Automatic
Both
Adaptations
Unsure

52. Who suggested you come for a driving assessment, e.g. DVLA, GP, memory clinic, healthcare professional?

53. If you have had a driving assessment before, please provide details below?

54. Typically where do you drive to on your average week?

55. If you don't currently drive, which methods of transport do you use?

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NOTE: ONLY PROVISIONAL LICENCE HOLDERS NEED TO ANSWER THE FOLLOWING FOUR QUESTIONS

If Full Licence holder move to Ethnic Origin section. Provisional Licence holders move to Question 57.

56. How many hours driving tuition have you taken?

57. Have you passed your theory test yet?

58. Have you previously participated in any practical driving tests?

59. How many practical tests have you taken?

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Ethnic Origin

If you choose not to complete this section, please check the box.

Does not wish to respond

If you have chosen not to respond, please press 'Next' below to proceed.

White

British
Irish
Any other white background

Mixed

White & Black Caribbean
White & Black African
White & Asian
Any other Mixed background

Please state other White background

Please state other Mixed background

Asian or Asian British

Indian
Pakistani
Bangladeshi
Any other Asian background

Black or Black British

Carribean
African
Any other Black background

Please state other Asian background

Please state other Black background

Chinese or other ethnic group

Chinese
Any other ethnic group

Other ethnic group

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Consent

Do you grant consent for details of your assessment to be discussed with a third party such as a family member, caseworker, health care professional etc? *

I authorise
I do not authorise

I give Herts Ability consent to send a copy of my driving assessment report to the DVLA on my behalf. *

I authorise
I do not authorise

I agree that the outcome of my assessment (including my report) can be sent to a healthcare professional (where specified) so they can support me further when discussing my fitness to drive. *

I authorise
I do not authorise

Your licence status

In order for us to conduct your assessment, we need to check your licence status in advance.

Please insert your full Driving Licence number and National Insurance (NI) number below.

This information is essential for us to check your driving licence before arrival. Once a licence check is complete, your National Insurance Number will be permanently removed from our systems.

Example National Insurance card:

Example National Insurance card

National Insurance (NI) Number *

It’s on your National Insurance card, benefit letter, payslip or P60. For example, ‘AB 12 34 56 C’.

Example driving licence number highlighted in blue:

Driving Licence Number

Please provide your full Driving Licence number. These details will be destroyed once your assessment has been completed.

If you have not provided a Driving Licence number, please tick the box below and provide the reason why.

I have not provided a Driving Licence number

Reason why you have not provided your Driving Licence number.

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Declaration

Signature. This is a required field. *

Clear Signature

Use your mouse pointer or finger to draw your usual signature. You can try as many times as you need by clicking or tapping the cross icon on the right to clear the box.

Date / Time *

Date

Time

Comment

Save and Resume Later

Your form entry has been saved and a unique link has been created which you can access to resume this form.

Enter your email address to receive the link via email. Alternately, you can copy and save the link below.

Please note, this link should not be shared and will expire in 30 days, afterwards your form entry will be deleted.

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Email *

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PAQ Form

Guidelines for completing this form:

Personal Details

Personal Details (continued)

Medical and Health Information

Medical and Health Information (continued)

Eyesight

Mobility and Physical Ability

Driving History

Driving History (continued)

NOTE: ONLY PROVISIONAL LICENCE HOLDERS NEED TO ANSWER THE FOLLOWING FOUR QUESTIONS

If Full Licence holder move to Ethnic Origin section. Provisional Licence holders move to Question 57.

Ethnic Origin

Consent

Your licence status

Please insert your full Driving Licence number and National Insurance (NI) number below.

Declaration

Driving

Mobility Scooters

Advice

Other Services

About

Contact

Make a Donation

PAQ Form

Guidelines for completing this form:

Personal Details

Personal Details (continued)

Medical and Health Information

Medical and Health Information (continued)

Eyesight

Mobility and Physical Ability

Driving History

Driving History (continued)

NOTE: ONLY PROVISIONAL LICENCE HOLDERS NEED TO ANSWER THE FOLLOWING FOUR QUESTIONS

If Full Licence holder move to Ethnic Origin section. Provisional Licence holders move to Question 57.

Ethnic Origin

Consent

Your licence status

Please insert your full Driving Licence number and National Insurance (NI) number below.

Declaration

Cookie Preferences

Make a Donation