LOCAL GOVERNMENT (MISCELLANEOUS PROVISIONS)
		ACT 1976
	MEDICAL REPORT ON AN APPLICANT FOR A HACKNEY CARRIAGE
		AND PRIVATE HIRE VEHICLE DRIVER'S LICENCE

NOTE FOR THE APPLICANT
This medical report cannot be issued free of charge as part of the National Health Service.  The applicant must pay the medical practitioner's fee, unless other arrangements have been made.  The Licensing Authority accepts no liability to pay it.

PART A - INFORMATION ABOUT THE APPLICANT
1.	Full Name: (BLOCK CAPITALS)  

                                                                                              Post Code

2.	Address:

	Tel No:
3.	Date of Birth:    
4.	Name and address of your present general practitioner or of the group practice with which you have been registered for the last 12 months.

Name:	
Address:	
                                                                                                                                 Post Code	

5.	I hereby consent to the Medical Advisor to the Licensing Authority receiving reports from my doctors and specialist about my medical condition.  If any matter affecting my fitness to drive arises:-

	(a)	In connection with my application for a Hackney Carriage and Private Hire Vehicle Driver's Licence
	(b)	During the period that a licence (if granted) is in force.

Applicant's Signature: 		  Date:  	
(Please sign in the presence of the medical practitioner who signs the report (Part B)
NOTES FOR THE DOCTOR - Please read these notes before undertaking the examination.
1.	Please complete Part B of this report, you may find it helpful to consult “Assessing fitness to drive - a guide for medical professionals” issued by DVLA, Swansea. (Website: http://bit.ly/1TLEcWA)

2.	Applicants who may be asymptomatic at the time of the examination should be advised that, if in future they develop symptoms of a condition which could affect safe driving and they hold any type of driving licence they must inform the Drivers Medical Group, DVLA, Swansea, SA99 1TU immediately.
	The Licensing Officer for Wyre Forest District Council must also be informed.

3.	Please tick the answer that applies and complete all answers.

4.	It is the Council's Policy that Group 2 medical standards will apply to all Hackney Carriage and Private Hire Vehicle Drivers that it licences.  The purpose of the report is to determine the applicant's fitness to be a 'Group 2' driver and it must be submitted with the application.  Failure to do so will delay the processing of this application.

MEDICAL STANDARDS REQUIRED
The medical standards required are higher than they are for ordinary driving entitlement.  These standards are briefly explained below:-

1.	Epilepsy attacks
	Applicants must NOT "have a liability to epileptic seizures".  With such a liability DVLA and the Local Authority must refuse or revoke the licence.

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2.	Diabetes
	Insulin treated diabetics may NOT obtain a licence UNLESS they held a licence valid at 1st April, 1991 and the Licensing Officer who issued the licence had knowledge of the insulin treatment before 1st January, 1991.

3.	Eyesight
	All drivers must be able to read in good daylight a number plate 20.5 metres (67 feet), and if glasses or contact lenses are required to do so, these must be worn whilst driving.  In addition:-

		(i)	Applicants who have not held a licence before must by law have both

•	a visual acuity of at least 6/9 in the better eye; or

•	a visual acuity of at least 6/12 in the other eye.

and	
•	if these are achieved by correction, the uncorrected visual acuity in both eyes must be no less than 3/60.  A driver who has an uncorrected acuity of less than 3/60 in only one eye may be able to meet the required standard.  Refer to 'At a Glance Guide to the current Medical Standards of Fitness to Drive' - A Guide for Medical Practitioners issued by DVLA, Swansea.

		(ii)	An applicant or licence holder who has held a licence before 1st March, 1992 but who does not meet the standard in (i) above may still qualify for a licence.  Information about the standard for such an applicant can be obtained from 'At a Glance Guide for Medical Practitioners for the current medical standards of fitness to drive' issued by DCLA, Swansea.

	An applicant or licence holder failing to meet the epilepsy, diabetes or eyesight regulations must be refused in law.

4.	In addition to those medical conditions covered by law, applicants or licence holders are likely to be refused if they are unable to meet the national recommended guidelines in the following cases:-

•	within 3 months of myocardial infarction, any episode or unstable angina, CABG or coronary angioplasty.

•	a significant disturbance of cardiac rhythm occurring within the past 5 years unless special criteria are met.

•	Suffering from or receiving medication for angina or heart failure.

•	Hypertension where the BP is persistently 180 systolic or over or 100 diastolic or over.

•	a stroke, TIA or unexplained loss of consciousness within the past 5 years.

•	Meniere's and other conditions causing disabling vertigo, within the past 1 year.

•	recent severe head injury with serious continuing after effects, or major brain surgery.

•	Parkinson's disease, multiple sclerosis or other "chronic" neurological disorders likely to affect limb power and co-ordination.

•	being treated for or suffering a psychotic or schizophrenic illness in the past 3 years, or suffering from dementia.

•	alcohol dependency or misuse, or illicit drug or substance dependency or use in the past 3 years.

•	insuperable difficulty in communicating by telephone in an emergency.

•	insuperable diplopia, or defect in the binocular field vision.

•	any other serious medical condition which may cause problems for road safety and hackney carriage and private hire driving.

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PART B

MEDICAL EXAMINATION
to be completed by the Doctor

Please answer all questions	

SECTION 1 VISION (Please see Eyesight Notes 3(i) to 3(ii) on page 2)

YES

NO

a.	Is the visual acuity as measured by the Snellen chart AT LEAST 6/9 in the better
	eye or AT LEAST 6/12 in the other?  (Corrective lenses may be worn)

b.	If corrective lenses have to be worn to achieve this standard,

YES

NO

		(i)	is the UNCORRECTED acuity AT LEAST 3/60 in the RIGHT eye?   

NO

YES

		(ii)	is the UNCORRECTED acuity AT LEAST 3/60 in the LEFT eye?   
			(3/60 being the ability to read the 60 line of the Snellen chart at 3 metres)                	

c.	Please state all the visual acuities for all applicants:

                               UNCORRECTED		CORRECTED (If applicable)

Right			   Left     	Right  	Left  	

d.	If there is NO perception of light in one eye, on what date did the applicant become
	monocular or lose the sight in one eye?		Date:

NO

YES

e.	Is there a full binocular field of vision? (central and/or peripheral)

NO

YES

f.	Is there uncontrolled diplopia?

SECTION 2 NERVOUS SYSTEM			YES	NO
								
a.	Has the applicant had major or minor epileptic seizure(s)?	

		(i)	Please give date of last seizure

		(ii)	Please give date when treatment ceased

b.	Is there a history of blackout or impaired consciousness within the past 5 years?	

c.	Is there a history of stroke or TIA within the past 5 years?

d.	Is there a history of sudden disability dizziness/vertigo within the last 1 year?

e.	Is there a history of chronic and/or progressive neurological disorder?
		(i)	If YES, please give details in SECTION 7

f.	Is there a history of brain surgery?
		(i)	if YES, please give date and details in SECTION 7

g.	If there a history of serious head injury?
		(i)	If YES, please give date and details in SECTION 7

h.	Is there a history of brain tumour, either benign or malignant, primary or secondary?
		(i)	If YES, please give details in SECTION 7

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SECTION 3 DIABETES MELLITUS				YES	NO

a.	Does the applicant have diabetes mellitus?
	If YES, please answer the following questions.
	If 'NO', proceed to SECTION 4

b.	Is the diabetes managed by:-

		(i)	Insulin?
			If YES, date started on insulin?

		(ii)	Oral hypoglycaemic agents and diet?

		(iii)	Diet only?

c.	Is the diabetic control generally satisfactory?

d.	Is there evidence of:-

		(i)	Loss of visual field?

		(ii)	Has there been bilateral laser treatment? If YES, please give date

		(iii)	Severe peripheral neuropathy?

		(iv)	Significant impairment of limb function or joint position sense?

		(v)	Significant episodes of hypoglycaemia?

		(vi)	Complete loss of warning symptoms of hypoglycaemia?

SECTION 4 PSYCHIATRIC ILLNESS				YES	NO

a.	Has the applicant suffered from or required treatment for a psychosis in the past 3 years?
		(i)	If YES, please give details in SECTION 7

b.	Has the applicant required treatment for any other psychiatric disorder within the past
	6 months?
		(i)	If YES, please give details in SECTION 7

c.	Is there confirmed evidence of dementia?

d.		(i)	Is there a history of alcohol misuse or alcohol dependency in the past 3 years?

		(ii)	Is there a history of illicit drug or substance use or dependency in the past 3 years?
			If YES to (i) or (ii) please give details in SECTION 7

SECTION 5 GENERAL					YES	NO

a.	Has the applicant currently a significant disability of the spine or limbs which is likely to
	impair control of the vehicle?
		(i)	If YES, please give details in SECTION 7

b.	Is there a history of bronchogenic or other malignant tumour with a significant liability to
	metastasise cerebrally?
		(i)	If YES, please give dates and diagnosis and state whether there is current evidence of
			dissemination.

c.	Is the applicant profoundly deaf?

d.	Could this be overcome by any means to allow a telephone to be used in an emergency?

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SECTION 6 CARDIAC

A.	Coronary Artery Disease
	Is there a history of:					YES	NO

		(i)	Myocardial Infarction?
			If YES, please give date(s)

		(ii)	Coronary artery by-pass graft?
			If YES, please give date(s)

		(iii)	Coronary Angioplasty?
			If YES, please give date(s)

		(iv)	Any other Coronary artery procedure? If YES, please give details in SECTION 7.

		(v)	Has the applicant suffered from Angina?

		(vi)	Is the applicant STILL suffering from Angina or only remains angina free by the
			use of medication?

		(vii)	Has the applicant suffered from Heart Failure?

		(viii)	Is the applicant STILL suffering from Heart Failure or only remains controlled
			by medication?

		(ix)	Has a resting ECG been undertaken?
			If YES, please give date

		(x)	Does it show pathological Q waves?

		(xi)	Does it show Left Bundle branch block?

		(xii)	Has an exercise ECG been undertaken (or planned)?
			If YES, please give date.

		(xiii)	Has an angiogram been undertaken?
			If YES, please give date and give details in SECTION 7

B.	Cardiac Arrhythmia				YES	NO

		(i)	Has the applicant had a significant documented disturbance of cardiac rhythm
			within the past 5 years?  If YES, please give details in SECTION 7

		(ii)	Has the arrhythmia (or its medication) caused symptoms of sudden dizziness
			or impairment of consciousness or any symptom likely to distract attention
			during driving within the past 2 years?

		(iii)	Has Echocardiography been undertaken? If YES, please give details in SECTION 7

		(iv)	Has an exercise test been undertaken? If YES, please give details in SECTION 7

		(v)	Has a PACEMAKER been implanted?

		(vi)	If YES, was it implanted to prevent Bradycardia?

		(vii)	Is the applicant now free of sudden and/or disabling symptoms?	

		(viii)	Does the applicant attend a pacemaker clinic regularly?

		(ix)	Has a Cardiac defibrillator been implanted or antiventricular tachycardia
			device been fitted?

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SECTION 6	CARDIAC (continued)				YES	NO

C.	Other Vascular Disorders
		(i)	Is there a history of Aortic Aneurysm with a transverse diameter of 5cm or more?
			(Thoracic or abdominal)

		(ii)	If YES, has the aneurism been successfully repaired?

		(iii)	Is there symptomatic peripheral arterial disease?

D. 	Blood Pressure
		(i)	Is there a history of hypertension with BP readings consistently greater than 180
			systolic or 100 diastolic?
			If YES, please supply most recent readings with dates

		(ii)	If treated does the medication cause any side effects likely to affect safe driving?

E.	Valvular Heart Disease
		(i)	Is there a history of valvular heart disease (with or without surgery)?

		(ii)	Is there any history of embolism?

		(iii)	Is there any history of arrhythmia - intermittent or persistent?

		(iv)	Is there persistent dilatation or hypertrophy of either ventricle?
			If YES, please give details in SECTION 7.

F.	Cardiomyopathy
		(i)	Is there established cardiomyopathy?

		(ii)	Has there been a heart or heart/lung transplant?
			If YES, please give details in SECTION 7.

G.	Congenital Heart Disorders
		(i)	Is there a congenital heart disorder?

		(ii)	If YES, is it currently regarded as minor?

		(iii)	Is the patient in the care of a Specialist clinic?
			If YES, please give details in SECTION 7.
										
SECTION 7 - NOTES

(Any essential or additional information should be given on a separate sheet of paper and attached)
										
SECTION 8 MEDICAL PRACTITIONER'S OPINION
In my opinion the applicant	IS			IS NOT		Considered physically fit to drive a Hackney Carriage/Private Hire vehicle	

Signature of the Registered Medical Practitioner 		       Date: 			
Name: (IN CAPITALS) 							
Address: 								
					 Post Code 	 Tel No. 				
                                                                                                                                                          (Inc STD Code)
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