ABN 61 760 960 480 Medical report

Please complete your licence and personal details and give this form to your practitioner.
Licence / Learner permit no.
Please print clearly in ink using BLOCK letters.
Personal and/or health information that we collect from you in connection with the administration of your driver licence will be used for that
Licence / Permit type purpose and may be used for other purposes permitted by the Road Safety Act 1986 and the Marine Safety Act 2010. Your personal and/or health
Car / Motorcycle / Light truck (LR) information may be disclosed to contractors and agents of VicRoads, the Victorian Institute of Forensic Medicine or other body advising VicRoads on
medical fitness of drivers, occupational therapists, law enforcement agencies, other road and traffic authorities including the Victorian Taxi Directorate,
Bus /Truck (MR, HR, HC, MC) the Transport Accident Commission, courts and other persons authorised to obtain it such as Transport Safety Victoria. You are required to give this
Marine information to VicRoads by the Road Safety Act 1986, Marine Safety Act 2010 and associated regulations. Failure to provide this information may
result in your application not being processed or driver licence records not being properly maintained or your authority to drive on your interstate driver
Personal watercraft endorsement licence/learner permit or overseas driver licence removed. For further information about our use of your personal and/or health information and your
rights of access to it, see VicRoads brochure Protecting your privacy or contact VicRoads. For other agencies or persons authorised to obtain your
Licence / Permit status personal and/or health information, you should contact the agency directly for further information about their use and your rights of access to it.
Current I agree to the practitioner named on this form completing the report and forwarding it to VicRoads and agree to VicRoads’ use and
­­­disclosure of personal and health information contained in the form in accordance with the above statement. I agree to pay all expenses
Applying for in connection with this report.
Variation to Signed OFFICE USE

Your personal details

Surname Date of birth D D M M Y Y Y Y

First given name Second given name

Home address Postcode

Examination – to be completed by a medical practitioner

You must complete this section You must complete this section
Visual acuity, unaided R 6/ L 6/ Binocular 6 / How long have you known/treated the patient? Years Months
Visual acuity, aided R 6/ L 6/ Binocular 6 / Yes No Do you know the medical history of the patient?

Does the patient have any of the following conditions? Please cross
Comments (Please specify medical condition and indicate how the patient’s
all circles that apply and provide details in Comments section. driving ability may be affected by the medical condition. Provide clinical data, final
Cardiovascular problems Please specify reason diagnosis and current treatment, including medication and any likely side effects.)

Diabetes – controlled by diet oral insulin

Hypoglycaemic reactions
Consciousness impaired or hospitalisation required?
(specify cause of reaction and date of last attack)
Epilepsy Date of last attack D D M M Y Y Y Y

Type of epilepsy

Mental/psychiatric disorder (specify disorder)

DEDJTR 11119/11 VRPIN00152 01.18 88104 Authorised and published by VicRoads, 60 Denmark Street, Kew, Victoria, 3101.
You must complete this section
Was psychiatric treatment or hospitalisation required?
(specify name of hospital, admission date, discharge date) Yes No The patient meets the national medical standards
to hold a licence/permit to drive a car (includes
Musculo-skeletal disorders light truck) or motorcycle.
Neurological disorders (excluding epilepsy)
Yes No The patient meets the national medical standards
Other (e.g. blackouts, cancer, dizziness, HIV/AIDS, metabolic/ to hold a licence to drive a bus or heavy truck.
endocrine, excessive use of alcohol and drugs, hearing, liver, renal,
respiratory, sleep, syncope and/or vestibular disorders) Yes No In assessing the patient, I am of the opinion
the patient is fit to operate a vessel safely.
Visual problems Visual field defect (to confrontation)
The patient has seen a specialist(s)
Practitioner’s details (please use BLOCK letters or official stamp)
A specialist report is required Specify
Name of practitioner
You must complete this section
Address
On road driving test required to determine fitness to drive Yes No
Postcode
Please specify reason
Phone Qualifications

Signature of practitioner
Restrictions should apply to patient’s driving (please specify)

Further examinations required Date D D M M Y Y Y Y

The patient is aware that this form is to be sent to VicRoads We recommend you send your report(s) to us by email or fax.
The patient is aware that if a follow-up medical certificate is required, If you prefer to post, please allow up to two weeks for postal delivery.
they are responsible for sending it to VicRoads. (Applicable to holders and Email [email protected] Fax (03) 9854 2307
applicants of marine licences or personal watercraft endorsements only.) Post PO Box 2504, Kew, Victoria 3010 Call 13 11 71
 Medical report
Notes VicRoads has a legal responsibility under section 17 of the Road To meet this responsibility, section 27 of the Road Safety Act 1986
Safety Act 1986 and the Marine Safety Act 2010 to ensure that all and the Marine Safety Act 2010 gives VicRoads the authority to ask
drivers have the appropriate skills and abilities, and are medically any motor vehicle or marine licence holder or applicant to provide
fit to hold a licence. This also applies to the authority to drive on an medical evidence of their suitability to drive and/or to undergo a
interstate driver licence/learner permit or overseas driver licence. driving assessment.

To the practitioner T he examination must be conducted in accordance with the national If you have any doubts about the information required, or wish to
medical standards Assessing Fitness to Drive for Commercial and Private discuss the case personally, please contact VicRoads Medical Review
Vehicle Drivers available at austroads.com.au. (vehicles) on 9854 2407 or Transport Safety Victoria (boats) on
This publication provides medical standards for licensing and clinical 1800 223 022.
management guidelines for health professionals in Australia. Indemnity – Victorian legislation provides legal indemnity to practitioners
who conduct an examination and provide VicRoads with an opinion on
V icRoads has expert medical advisors who assist in determining fitness
the basis of that examination.
to drive when medical conditions are complex. VicRoads Medical Review
will be greatly assisted if you provide all relevant details. All information Criminal liability and insurance – Health professionals may be liable
is treated in accordance with the law. under civil law in cases where a court forms the opinion that they have
not taken reasonable steps to ensure that impaired drivers drive only
If you have doubts about your patient’s fitness to drive, you may
in circumstances that do not place them and other members of the
like to suggest a driving assessment. This does not apply to marine
community at increased risk. Professional indemnity insurers are aware
licence holders.
of the potential liability of health professionals and may reasonably expect
health professionals to comply with the national medical standards.

To the applicant Y ou must make an appointment with your practitioner. As the You should let your doctor know if you hold or are applying for a
examination and completion of this report may take longer than heavy vehicle licence, as the medical requirements for drivers of such
a routine consultation, you are advised to inform your doctor vehicles are stricter. If you are required to provide a medical report to
(or the receptionist) that you are attending for this purpose. other agencies it is in your interest to keep a copy of this report.
Y ou should make the doctor aware of any medical conditions you may Withdrawal of licence – If VicRoads withdraws your licence on the
have. If the medical report has been requested for a particular reason, basis of a medical report, you may be relicensed when you provide
you should let your practitioner know this reason. medical evidence which indicates that you have met the national
Y ou are required by law to advise VicRoads of any serious or chronic medical standards and are qualified to be relicensed. You also have
medical condition or disability that may affect your ability to drive. the right of appeal to a Magistrates’ Court.
If you provide this information, your doctor can advise VicRoads,
on your behalf, using this form.
Y ou should take any corrective lenses and hearing aids that you
normally use, to the examination.

VicRoads driving  here there is a concern about a person’s ability to drive safely,
W The on-road test is conducted in a vehicle with dual controls
assessment a driving test is necessary. fitted with automatic transmission. Customers are allowed time to
(Not applicable to When retesting current licence holders the on-road test may commence become familiar with the vehicle. The licence may be immediately
marine licences) from the person’s home, ensuring that the customer is tested in a familiar suspended, or the authority to drive on an interstate driver licence/
area and allowing a local area restriction to be imposed if appropriate. learner permit or overseas driver licence may be immediately
removed, if the test is failed.

Occupational therapy Victorian law gives specially trained occupational therapists the right to The on-road test takes a standard approach but can be designed to
driving assessment conduct a driver assessment where there is a medical concern about meet individual needs. It is conducted in a vehicle with dual controls
(Not applicable to the customer’s ability to drive safely. The aim of the occupational accompanied by a driving instructor and where necessary set up
marine licences) therapy assessment is to assist people with impairments to resume with special requirements or modifications to meet the needs of the
or continue driving. There are two components of the assessment. customer. The test is structured to assess the impact of injury, illness
The off-road assessment aims to evaluate the person’s fitness. or the ageing process on driving skills such as judgement, decision
This involves an interview, vision screen, cognitive function test, making skills, observation and vehicle handling.
assessment of physical strength, motor skills, reaction time, road
law and road craft. The need for specialist equipment or vehicle
modifications is considered at this time.

Licence conditions If appropriate, the customer’s medical practitioner may make If the practitioner believes that vehicle modifications are necessary
recommendations to VicRoads, allowing the customer to (e.g. hand controls, left foot accelerator), or a prosthesis is necessary
continue driving on a conditional licence (e.g. corrective lenses, to drive safely, or that a local area driving restriction is appropriate, the
no night driving). customer will need to demonstrate the ability to drive safely with these
An occupational therapist after completing a driving assessment restrictions. In these cases a driving assessment is necessary.
may also make recommendations to VicRoads. The final decision
is made by VicRoads.

Email: [email protected] Fax: (03) 9854 2307

Post: VicRoads Medical Review, PO Box 2504, Kew, Victoria, 3101 Call: 13 11 71 (TTY 13 36 77, Speak and Listen 1300 555 727) Web: vicroads.vic.gov.au