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Driver Evaluation Intake Form

Crotched Mountain > Education > Driver Evaluation and Training  > INTAKE FORM                                        

Client Information 
Name: Date of Birth:
Address:
City:         State: Zip:
Tel: E-mail:
If applicable; seated height in wheelchair (floor to top of head):
If Applicable; combined weight (client plus wheelchair):
Parent/Guardian Information (if applicable and different)
Name:    
Address:
City:        State: Zip:
Tel:   E-mail:
Funding
Private Pay:                                                          Yes No
If yes, have rates been explained to you?          Yes No
If no, name of funding source:
Vocational Rehabilitation
Workman's Comp                 Company Name:
Contact Person:
Address:
Telephone: Email:
Reason for Referral
Diagnosis: Onset:
Manifestation:
Medical and other Information
Referring Physician: (if applicable):
Address: Telephone:
Do you have Medical Clearance to drive? Yes No N/A
Do you have Seizures? Yes No Date of last seizure:
Dominant Hand: Left Right
Medications:                                              Yes     No
Driving History
Do you have a driver's License?              Yes      No What State:
Is your license under any suspensions, revocations, cancellations?
Yes     No
If Yes, what are they?
Where do you plan of driving?  Rural City Highway All of the above
Unlicensed applicants only:
Have you attended Driver Education Class?
Yes     No
If yes, do you have a certificate of completion?
Yes     No
Physical Abilities
Do you have problems with any of the following?  (Please check all that apply)
Upper body weakness
Limited Hand Function
Balance problems/unsteadiness
Difficulty moving Arms
Difficulty moving Legs
Difficulty moving head
Visual Difficulties
Coordination Limitations
Do you use any of the following?
Manual Wheelchair
Power Wheelchair is the joystick:  
    Right Hand Left Hand
Walker
Crutches
Cane
Other:
Do you require any adapted seating or positioning devices? (i.e. custom molded backrest, pressure relieving cushion, cutouts for leg length discrepancy, etc.)
Yes     No
Can you independently transfer into/out of a vehicle?
Yes     No
Cognitive Abilities
Do you have problems with the following:
Difficulty concentrating on task
Memory difficulties
I have completed the driver evaluation history form fully and to the best of my abilities.  All of the information provided is factual.
______________________________________________      Date:
Client Signature

(You or your guardian will be asked to sign this form when you come in for your first evaluation.)

 

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