Government of Western Australia
Department of Transport
Please answer the questions by ticking the correct box. If you are not sure,
leave the question blank and ask your health professional what it means.
PATIENT QUESTIONNAIRE
The Department of Transport has a legal responsibility to ensure that all drivers have the appropriate skills and abilities, and are medically t to drive a vehicle.
To meet this responsibility, legislation provides the Department of Transport the authority to request any driver’s licence holder or applicant to provide medical
evidence of their suitability to drive and/or undergo a driving assessment. Payment for the medical examination is the responsibility of the licence holder.
1. Make an appointment with your health professional.
• As the examination may take longer than a routine consultation,
you should advise that your appointment is for a driving medical
assessment.
2. Complete the Patient Questionnaire section.
3. Complete your personal details on the Medical Assessment Certicate
and circle the authorisation/extensions you are proposing to drive and/
or retain.
4. If you are completing a ‘Medical Assessment Certicate Fitness to
Drive’ (M107A) sign the consent to release information at the top right
hand of the page.
5. If you are completing a ‘Medical Assessment Certicate Senior
Driver’s Licence Renewal Declaration’ (M108A) complete the driving
history, medical questions and sign the consent to release information
at the bottom of the page.
6. Take the completed Patient Questionnaire and the Medical Assessment
Certicate to the appointment with your health professional.
• If you wear spectacles, hearing aids etc, please take them to the
examination.
• Please have a list of the names and dosages of your medications to
show the health professional when you attend your appointment.
• If the medical report has been requested for a particular reason, you
should let your health professional know.
• Let your health professional know if you are applying to hold, or
already hold, a heavy vehicle driver’s licence, a driving instructor’s
licence, or a Passenger Transport Driver authorisation. You will
need to be assessed against the national medical standards for
commercial vehicle drivers which is more stringent than private
standards.
On completion of the examination the health professional will forward the
medical assessment certicate to the Department of Transport. For further
information please contact 13 11 56.
YES NO
Are you currently being treated by a health
1
professional for any illness or injury?
Are you receiving any medical treatment or
2 taking any medication (either prescribed or
otherwise)?
Have you ever had, or been told by a health professional that
3
you have, any of the following?
3.1 High blood pressure
3.2 Heart disease
3.3 Chest pain, angina
3.4 Any condition requiring heart surgery
3.5 Palpitations/irregular heartbeat
3.6 Abnormal shortness of breath
3.7 Head injury, spinal injury
3.8 Seizures, ts, convulsions, epilepsy
3.9 Blackouts, fainting
3.10 Stroke
3.11 Dizziness, vertigo, problems with balance
3.12 Double vision, diculty seeing
3.13 Colour blindness
3.14 Kidney disease
3.15 Diabetes
3.16 Neck, back or limb disorders
3.17 A psychiatric illness, or nervous disorder
Hearing loss or deafness or had an ear
3.18
operation or use a hearing aid
Do you have diculty hearing people on the
3.19 telephone (including use of hearing aid if
worn)?
Any other serious injury, illness, operation,
3.20
or have you been in hospital for any reason?
Have you ever had, or been told by a health
4.1 professional that you have, a sleep disorder,
sleep apnoea or narcolepsy?
Has anyone noticed that your breathing
4.2 stops or is disrupted by episodes of choking
during your sleep?
Patient Questionnaire continued over page.
DRIVER/APPLICANT INSTRUCTIONS
Medical Assessment Instructions
M106A
HEALTH PROFESSIONAL INSTRUCTIONS
The examination must be conducted in accordance with the current national
medical standards described in the Austroads publication - Assessing
Fitness to Drive. This publication is available online at www.austroads.
com.au and details the examination process and provides an examination
proforma to guide you.
For privacy reasons these Medical Assessment Instructions must not
be returned to DoT. Medical information relevant to the driver licensing
should be included on the Medical Assessment Certicate. The Medical
Assessment Certicate and any other information relevant to the patient’s
tness to drive must be returned to the Department of Transport by the
medical professional or the patient via:
• Email: driverservices@transport.wa.gov.au;
• Electronic Medical Assessment: via Medical Director software or
United Health Group MedEBridge; or
• Post: Department of Transport,
GPO Box R1290,
PERTH WA 6844
Please mark as ‘Condential’.
If you have any doubts about the information required, or wish to discuss the
case personally, please contact the Department of Transport on 1300 852 722.
Indemnity - State or Territory legislation provides legal indemnity to
practitioners who conduct an examination and provide Driver Licensing
Authorities with an opinion on the basis of that examination.
Criminal Liability & Insurance - Health professionals may be liable under
civil law in cases where a court forms the opinion that they have not taken
reasonable steps to ensure that impaired drivers drive only in circumstances
that do not place them and other members of the community at increased
risk. Professional indemnity insurers are aware of the potential liability of
health professionals and may reasonably expect health professionals to
comply with the national medical standards.
