Drivers Medical Questionnaire Drivers Medical Questionnaire Medical Questionairre Required For FORS D6 (Drivers Health & Eyesight) COMPANY DRIVERS MEDICAL QUESTIONNAIRE – (Medical in Confidence) As part of our commitment to FORS (Fleet Operator Recognition Scheme) We are obliged to have all our drivers answer a short medical questionairre You will be asked for your driving licence number if you drive company vehicles, (so please ensure you have it to hand) Go to top Driver Details Date * Full Name * Phone * Email * Company Division * OHL Construction TeamIsolations TeamWelding TeamDe Vegetation TeamPlant & Transport TeamSupport Services Please Choose * I Drive Company VehiclesI Do Not Drive Company Vehicles Driving Licence Number * Medical Questionnaire Do you have, or have you ever had any of the following? Impairment of vision. YES NO Difficulty seeing well enough to drive when there is glare or poor visibility such as fog. YES NO Fits, epilepsy, fainting or blackouts. YES NO Attacks of dizziness or vertigo. YES NO Weakness, loss of sensation or clumsiness affecting part of your body. YES NO Severe head injury or brain surgery. YES NO Difficulty hearing normal conversation. YES NO Trouble with your back or neck causing absence from work or a change in duties. YES NO Any form of cancer. YES NO Diabetes. YES NO Psychiatric illness including depression or anxiety. YES NO Dependency on or misuse of alcohol, drugs or other substance YES NO Disease of the heart or circulation including angina, heart attack or heart valve problems. YES NO High blood pressure. YES NO Any serious medical condition that may result in you being a danger to yourself or others when driving. YES NO Abnormal heart rhythm or irregular heartbeat. YES NO Are You Taking Any Medication? YES NO List any medication that you are taking. If you answered yes to any question please write any comments in this space. By signing & submitting this questionairre I confirm that all my answers are true. * signature keyboard Clear If you are human, leave this field blank. Submit