Sheffield Memory Service & Complex Geriatric Care

Specialist in Memory, Parkinson’s disease, Stroke, Dizziness, Falls & Complex Ageing

Sheffield Memory Service &
Complex Geriatric Care

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Sheffield Memory Service & Complex Geriatric Care

Specialist in Memory, Parkinson’s disease, Stroke, Dizziness, Falls & Complex Ageing

Driving and Safety Review Checklist

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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 [patient] safe and plan the right support.

Patient details

Full Name *

First

Last

Date of birth *

1. Driving

Do you currently drive? *

Yes - regularly
Yes - occassionally
No

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

No problems
Getting lost on familiar routes
Difficulty judging speed or distance
Missing road signs or traffic lights
Confusing the pedals or gears
Near misses
Road traffic accident (flag)
Reduced confidence while driving
Family members have expressed concerns

feel you Do

Has your driving licence status changed? *

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

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?

Have you become more unsteady? *

No
Slightly
Significantly

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? *

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

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
Scam phone calls or emails
Financial exploitation concerns
Family now manages finances
None of the above

Do you currently live alone? *

If yes, do you feel safe living alone?

Yes
Mostly
No
Not applicable

6. Emergency situations and overall impression

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

Hospital admission
Emergency department attendance
Calling emergency services
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 [patient] safe at home? *

Possibly Yes
Yes
No

Additional comments

Together We Can Do More

Spire Claremont Hospital

0114 263 0330

Circle Thornbury Hospital

0114 266 1133

Sheffield Memory Service & Geriatric Care

Private Geriatrician in Sheffield specialising in memory assessment, dementia diagnosis, Parkinson’s disease, Stroke & TIA, dizziness, falls and complex ageing care.

This service provides rapid access to consultant-led Comprehensive Geriatric Assessment for older adults in Sheffield and South Yorkshire.

Private Geriatrician Clinics in Sheffield

Spire Claremont Hospital
401 Sandygate Road
Sheffield S10 5UB

Circle Thornbury Hospital
312 Fulwood Road
Sheffield S10 3BR

📍 Sheffield, South Yorkshire, UK

Home visits also available across Sheffield and surrounding areas.

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