1) Do you have impaired vision in one or both eyes even when wearing glasses or contact lenses?
Can you see well when wearing your glasses or contact lenses? If so, fill in 'no'.
If you cannot see well even when wearing your glasses or contact lenses, fill in 'yes'.
1a) Do you drive with or do you wish to drive with a bioptic telescope (BTS)?
A BTS is a device used to improve vision. Go to www.auto-mobiliteit.org for more information.
2) Are you being treated or have you ever been treated by an ophthalmologist for any reason other than for your glasses or contact lenses?
For example, for treatment of cataracts or for laser eye surgery.
3) Do you have diabetes?
4) Do you have chronic kidney disease (reduced kidney function)?
Also fill in 'yes' if you undergo dialysis.
5) Do you have a lung disease (COPD), a blood disorder or have you had an organ transplant?
6) Do you have a heart disorder or vascular disorder?
Fill in 'yes' if you have a pacemaker or an ICD, for example. Or if you have had a heart attack or open-heart surgery. Or if you have a blood vessel disorder, such as arteriosclerosis, or if you have had an angioplasty or vascular surgery.
6a) Do you have an ICD?
6b) Do you have a LVAD?
7) Have you ever been diagnosed with a disorder of your brain, spinal cord or nervous system (for example, a stroke or muscular disease)?
This includes, for example:
- stroke, brain haemorrhage, brain tumour, brain injury;
- Parkinson's disease, multiple sclerosis, ALS;
- muscle weakness;
- dementia (all forms);
- spinal cord injury , nerve injury or neuropathy.
Also fill in 'yes' if you have been diagnosed with a brain or nervous system disorder that is not included in this list. You can provide more details in the following questions.
7a) Have you been diagnosed with a form of dementia or MCI?
Also fill in 'yes' if you do not have dementia or MCI, but you do have cognitive problems, thinking and remembering information.
7b) Have you ever suffered a stroke or brain haemorrhage?
This concerns problems with the blood supply to your brain and the blood vessels in your brain. In the following questions you can provide more details.
7c) Have you ever been diagnosed with a malformation of a blood vessel in your brain (known as a brain arteriovenous malformation), without first suffering a bleed in your brain?
Sometimes, a doctor may discover a malformation of a blood vessel in the brain by chance, for instance on a brain scan or MRI. Fill in 'yes' if you have been identified as having a blood vessel malformation in the brain, without an intracranial bleeding.
7d) Do you have a nervous system disorder?
This includes, for example, Parkinson's disease, multiple sclerosis, ALS or neuropathy.
7e) Do you have a muscular disease?
Go to www.spierziekten.nl for more information about muscular diseases.
7f) Do you have a brain tumour? Or have you ever had one?
Brain tumour means all benign and malignant tumours within the skull.
7g) Do you have a brain disorder or nervous system disorder that has not yet been mentioned?
Fill in 'yes' if you have a brain or nervous system disorder which has a negative effect on your vision, thinking or movement. For example, spinal cord injury, nerve damage or a brain injury caused by an accident.
8) Have you ever had an epileptic fit?
There are many types of epileptic fit. For this question, the type of epileptic fit does not matter. Fill in 'yes' if you have ever had an epileptic fit of any kind.
9) Have you ever experienced abnormal sleepiness during the day?
Fill in 'yes' if you have ever felt so sleepy that you were not able to stay awake. Consider, for example, disorders such as sleep apnoea and narcolepsy.
10) In the last three years, have you, on more than one occasion, suddenly lost consciousness (for example, fainting)?
Sudden loss of consciousness can have many causes. Fill in 'yes' if you have suddenly lost consciousness, whatever the reason, on more than one occasion.
11) In the past year, have you had attacks of dizziness due to Meniere’s disease?
12) Have you ever been diagnosed with any other psychological or psychiatric disorder?
Fill in 'yes' if you have ever consulted a general practitioner or psychiatrist who diagnosed you with a psychiatric disorder. Consider, for example, depression, psychosis or an anxiety disorder. But also ADHD or autism.
12a) Have you ever been diagnosed with depression or bipolar disorder?
12b) Have you ever had an episode of psychosis or do you have schizophrenia?
Fill in 'yes' if a doctor has diagnosed you with schizophrenia. Also fill in 'yes' if you have ever had an episode of psychosis.
12c) Do you have an anxiety disorder?
12d) Do you have ADHD or ADD?
Fill in 'yes' if you currently have a diagnosis of ADHD or ADD. Fill in 'no' if you were diagnosed as a child, but your treatment ended before you turned 16. In that case, a doctor decided that treatment was no longer necessary. You no longer have symptoms and you do not use medication. Not sure? Then we recommend that you first discuss this with your general practitioner.
12e) Have you ever been diagnosed with autism or a form of autism, such as PDD-NOS, McDD or Asperger syndrome?
12f) Do you have any other psychological or psychiatric disorder not mentioned in the previous questions?
13) In the last five years, have you excessively used (abused) alcohol, drugs or other addictive substances?
Fill in 'yes' if:
- it is difficult for you to function without alcohol or drugs;
- you regularly drive under the influence of alcohol or drugs;
- you have been treated for alcohol or drug abuse within the last five years.
Not sure whether you abuse alcohol or drugs? Then take the test on: www.jellinek.nl
14) Do you use medications that can have a negative affect on your ability to drive?
This concerns medicines that can make you sleepy or drowsy, or medicines with serious side effects. There will often be a warning on the packaging, but not always. However, it will always be mentioned in the patient information leaflet. Not sure? On the website www.rijveiligmetmedicijnen.nl you can check whether you are taking a medicine that means you should avoid driving.