Keys to Independence (Driving Program)

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Below please fill out the information of the patient to be evaluated. If you are completing the form on behalf of someone else, your contact information should go on the previous page.

Name

First NameLast Name

Date of Birth

Date

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact Name

First NameLast Name

Emergency Contact Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Relationship of Contact to Patient

Primary Care Physician

First NameLast Name

Referring Physician

First NameLast Name

Referring Physician Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Reason for evaluation (brief reason for need and important diagnoses in medical history that could affect driving):

Seizure history?

Date of last seizure, skip if not applicable

Date

Visual field deficit?

If you answered "yes" to the previous question, describe the visual field deficit

Driver's license is active?

Currently driving?

Accidents or fender benders in last 3 years?

History of becoming lost or confused while driving?

Check that you understand the following:

Keys to Independence (Driving Program)

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