EzyReg Account - Medical - Self Assessment

Medical - Complete your self assessment

Before you start

As you hold a car licence, are aged over 75 and do not have a medical condition recorded, you are required to complete an annual self assessment of your fitness to drive.
This assessment is for you to consider and assess your physical and mental ability to safely drive a vehicle to ensure you are not placing yourself or other road users at risk.
Based on the answers you provide you may be required to have a doctor complete a medical/eyesight examination.

Name	Licence No.	Licence expiry	Self assessment due date

Answer self assessment questions

Please answer each question below by selecting either Yes, No or Unsure.

If you are taking medication for a condition, please answer Yes to that condition.

Have you had a blackout in the last 12 months?

Yes No Unsure

Have you had a heart attack, other heart problem or stroke? (e.g. heart failure, bypass grafting, angina, atrial fibrillation, stroke, etc)

Yes No Unsure

Do you have high blood pressure that is uncontrolled and above 200 / 110?

Yes No Unsure

Do you have diabetes that requires medication?

Yes No Unsure

Do you have severe arthritis or other condition which limits movement? (e.g.amputation)

Yes No Unsure

Do you have a neurological condition? (e.g. dementia, epilepsy, multiple sclerosis, Parkinson’s disease, etc)

Yes No Unsure

Do you have a mental health or nervous disorder? (e.g. chronic depression, anxiety disorder, schizophrenia, etc)

Yes No Unsure

Do you have a chronic sleep disorder? (e.g. sleep apnoea, narcolepsy)

Yes No Unsure

Do you have an alcohol or drug disorder? (e.g. drug dependence or heavy alcohol use)

Yes No Unsure

Do you have an eye or vision condition? (e.g. cataracts, glaucoma, one-eye vision, etc)

Yes No Unsure

Are you required to wear glasses or contact lenses while driving?

Yes No Unsure

It is an offence to make a false or misleading statement. I hereby declare that I have truthfully answered the above questions.

If you would like to have the ‘corrective lenses’ restriction removed from your licence please cancel this transaction and have a medical practitioner (doctor) complete Part C: Eyesight Examination and Part D: Medical Practitioner’s Declaration of your self assessment form and return it to Service SA. Otherwise press OK to continue and lodge your self assessment, noting the corrective lenses restriction will be retained on your licence.

You are required to take the paper self assessment form we posted to you to a medical practitioner and have them complete the rest of the form.

Do you still have the paper self assessment we posted to you?

Yes No

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