Driving and Safety Review

This form is for your appointment with Dr Jha. It is not checked out of hours, so please don’t use it for anything urgent: call 999 in an emergency, or NHS 111 or your GP for other urgent problems.

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- Step 1 of 7

This checklist covers driving, mobility, home safety, and related areas since your last review. Please answer as accurately as you can — there's no need to feel concerned about any individual answer; it simply helps us keep you safe and plan the right support.

Patient details

Full Name *

First

Last

Date of birth *

Next

1. Driving

Do you currently drive? *

• Yes - regularly
• Yes - occassionally
• No

Since your last review, have you experienced any problems while driving? *

• Family members have expressed concerns
• No change
• Informed the DVLA
• Licence surrendered or revoked
• Not applicable

Has your driving licence status changed? *

• No change
• Informed the DVLA
• Licence under review
• Licence surrendered or revoked
• Not applicable

Next

2. Falls and mobility

Since your last review, have you had any falls? *

• No
• One fall
• Two or more falls

Did any fall result in injury requiring medical attention?

• Yes
• No

Have you become more unsteady? *

• No
• Slightly
• Significantly

Next

3. Home safety and medication safety

Have you had any of the following at home? *

• Left the cooker or oven on
• Forgotten recipe while cooking
• Difficulty using household appliances
• Fire or smoke alarm incident
• Left taps running
• Difficulty locking doors
• None of the above

Do you take your medication correctly? *

• Independently
• With reminders
• Family or carer prepares medication
• Medication administered by carers
• Frequently forget doses

Have you accidentally taken too much or too little medication? *

• Yes
• No

Next

4. Disorientation and wandering

Have you become lost or disorientated? *

• No
• Inside your home
• Outside near home
• While walking
• While shopping
• While driving

Have you wandered away from home or become difficult to find? *

• No
• Once
• more than once

Do you currently have any of the following in place? *

• Door or exit alarm
• Key safe
• Pendant or personal alarm
• GPS tracker
• None of the above

Next

5. Finances and living situation

Since your last review, have you experienced any of the following? *

• Difficulty paying bills
• Difficulty managing bank accounts
• Unusual spending
• Financial exploitation concerns
• Family now manages finances
• None of the above

Do you currently live alone? *

• Yes
• No

If yes, do you feel safe living alone?

• Yes
• Mostly
• No
• Not applicable

Next

6. Emergency situations and overall impression

Have you had any of the following since your last review? *

• Calling emergency services
• Emergency department attendance
• Hospital admission
• Police involvement because of confusion
• None of the above

Compared with six months ago, do you feel your safety has changed? *

• Much safer
• Slightly safer
• No change
• Slightly less safe
• Much less safe

Does your family or carer have any concerns about your safety? *

• No concerns
• Mild concerns
• Moderate concerns
• Significant concerns

Do you feel additional support is needed to keep you safe at home? *

• Possibly Yes
• Yes
• No

Additional comments

2. become of

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