HISTORY:
Presents for a driving license assessment
Required because of:
Type of license:
Current complaints:
Past medical history:
Medications: ,
Adverse effects:
Social history:
Smoking: , pack-years
Alcohol: , drinks per
Recreational drugs: ,
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Eyes: -R: , -L: ,
Ears: -R: , -L:
Neck:
Heart: ,
Lungs: ,
Abdomen: , , ,
Musculoskeletal: joints ,
Neurologic: cranial nerves , strength , sensation , reflexes , cerebellar function , gait
Mental status: , , speech , mood , thought process , , judgment
ASSESSMENT:
PLAN:
- Vision test
- Hearing test
- Cognitive assessment
- Reassessment of medications that may impair driving
- Referral to optometrist
- Referral to audiologist
- Referral to neurologist
- Referral to occupational therapist
- Driving license form filled
- Follow-up in