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Neurology Memory Clinic Driving Assessment (301388-DT)

Neurology Memory Clinic Driving Assessment (301388-DT) - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires



Patient Name

DOB:

MR #

Date: _______________________________

UWH# 301388-DT (Rev 05/06/16) Scan to Questionnaire-Health NEUROLOGY MEMORY CLINIC DRIVING
ASSESSMENT

UW Health uwhealth.org
(University of Wisconsin Hospitals and Clinics Authority)
NEUROLOGY MEMORY CLINIC DRIVING
ASSESSMENT
1. How many miles a week does the patient drive? _________________________
2. How many times has the patient been stopped or ticketed for a traffic violation in the last three years?
0 1 2 3 4 or more
3. How many accidents has the patient been in, or caused, within the last three years?
0 1 2 3 4 or more
4. In how many accidents was the patient at fault in the last three years?
0 1 2 3 4 or more
5. I have concerns about the patient’s ability to drive safely.
Strongly Disagree Disagree No Opinion Agree Strongly Agree

6. Others have concerns about his/her ability to drive safely.
Strongly Disagree Disagree No Opinion Agree Strongly Agree

7. The patient has limited amount of driving that he/she does.
Strongly Disagree Disagree No Opinion Agree Strongly Agree

8. He/She avoids driving at night.
Strongly Disagree Disagree No Opinion Agree Strongly Agree

9. He/She avoids driving in the rain.
Strongly Disagree Disagree No Opinion Agree Strongly Agree

10. He/She avoids driving in busy traffic.
Strongly Disagree Disagree No Opinion Agree Strongly Agree

11. The patient will drive faster than the speed limit if the patient thinks he/she won’t be caught.
Strongly Disagree Disagree No Opinion Agree Strongly Agree

12. The patient will run a red light if the patient thinks he/she won’t be caught.
Strongly Disagree Disagree No Opinion Agree Strongly Agree

13. The patient will drive after drinking more alcohol than the patient should.
Strongly Disagree Disagree No Opinion Agree Strongly Agree
14. When he/she gets angry with other drivers, the patient will honk the horn, gesture, or drive up too closely to
them.
Strongly Disagree Disagree No Opinion Agree Strongly Agree




Signature of Patient/Representative _________________________________Date: __________ Time: __________AM/PM
If signed by person other than the patient, print name and state relationship and authority to do so.

Print Name: _____________________________________Relationship: __________________________________

Patient is:  Minor  Incompetent / Incapacitated
Legal Authority:  Legal Guardian  Parent of Minor
 Health Care Agent  Other _____________________

Reviewed by: ______________________________________________________ Date: ______________ Time: __________ AM/PM