Fillable DECLARATION OF MEDICAL FITNESS DVLA GROUP 2 STANDARDS (Rochdale Metropolitan Borough Council)

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DECLARATION OF MEDICAL FITNESS DVLA GROUP 2 STANDARDS (Rochdale Metropolitan Borough Council)

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The DECLARATION OF MEDICAL FITNESS DVLA GROUP 2 STANDARDS (Rochdale Metropolitan Borough Council) form is 2 pages long and contains:

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ROC
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BOROUG
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DECLARATION OF MEDICAL FITNESS
DVLA GROUP 2 STANDARDS
Driver Details
Name:
Address:
DOB:
Licence No.:
Since your last medical, dated __________________________, have you had any medical issues
associated with the following (medical issues would constitute any visits to the doctor/hospital with
regard the below which resulted in further treatment being necessary);
Yes No
Eyesight
Neurological disorders (i.e. stroke/seizures/tumours/haemorrhage/brain injury or
surgery/Parkinson’s/narcolepsy)
Diabetes (i.e. new diagnosis or changes to previously diagnosed condition)
Heart (i.e. angina/heart attacks/bypass surgery/ arrhythmias/ pacemakers/ heart
disease/heart failure)
Blood Pressure (i.e. any changes to condition that requires treatment for high or low blood
pressure)
Psychiatric Illness
Alcohol or drug misuse/dependence
Sleep conditions (i.e. sleep apnoea/excessive sleepiness)
If you have answered yes to any of the above, please provide further details:
Are you currently taking any medication which you have been advised may affect your
ability to drive? If yes, please provide details, including the dosage:
Declaration:
• I understand as part of my licence conditions I am required to notify the Licensing Service of
any medical conditions since my last medical was completed.
• I declare the information I have provided above is true to the best of my knowledge.
• I understand that if the information I have provided is found to be false, or I am found to have
intentionally omitted information, I will be in breach of my licensing conditions and could face
having my licence suspended or revoked.
• I declare that should there be any changes to my medical condition since the date of this
declaration, and the time I have had a new Group 2 Medical completed by my GP, I must
inform the Licensing Service immediately.
Signed____________________________________
Print Name________________________________
Dated_____________________________________
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DECLARATION OF MEDICAL FITNESS DVLA GROUP 2 STANDARDS (Rochdale Metropolitan Borough Council)

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Completed 6 February 2021

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