Health Questionnaire

Please fill out the following form.

First name*

Last name*

Email*

Date of birth*

Month

Day

Year

Have you been hospitalized in the last 12 months?*

Yes

Are you suffering from a medical condition, illness or injury?*

Yes

If you answered yes to any of the questions above, please supply additional information.*

Be as specific or generic as you wish.

Do you have any limitations of movement or any pain in your body that affects driving?*

Yes

Do you have any allergies or medical conditions that require monitoring or vigilance?*

Yes

Do you have any of the following limitations on vision?*

Sun Sensitivity

Headlight Sensitivity

Focus challenges in one or both eyes

Near Sighted

Far Sighted

Concerns driving in rain, snow or at night

Lack of Depth Perception

Other

If you wear glasses do you identify as "legally blind" without your glasses or corrective lenses?

Yes

If you require an emergancy medical device such as an EpiPen or a rescue inhaler we require that you have those with you for each session. Please list any devices required below. *

If none, please just say: "none"

Initials*

I declare that the info I’ve provided is accurate and complete.

Concierge Driving Coach

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Westborough, MA

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