CONFIDENTIAL ASSESSMENT APPLICATION
SECTION A: ABOUT YOU, GENERAL INFORMATION
Title: Mr
Mrs
Miss
Ms
Dr
Other
Please fill out the form
using BLOCK capitals.
If you have difficulty
completing this
application form, please
contact us for help.
Tel: 01872254920
Surname:
First Name(s):
Address:
Postcode:
In case we need to contact you or leave you a message, please tell us your;
Telephone number:
Mobile telephone number:
Email address:
Can we use this e-mail address to send you your assessment report? YES
Date of birth:
General Practitioner Name:
Telephone Number:
General Practitioner Address:
Postcode:
Ethnic Group:
NO
SECTION B: ABOUT YOU and YOUR DIAGNOSIS.
Please tell us about your Medical Condition, Diagnosis or Disability.
If you know the name of your Medical
Condition please write it here. If you
have a non-specific medical condition,
please give as much information as you
can (e.g. back problems or problems
with concentration)
How long have you had this Medical Condition / Diagnosis or Disability?
Give as much detail as
possible. For example, are
your limbs affected by
restricted movement or
lack of strength?
Please describe how your medical condition affects you.
Please list any medication you take.
When and where did you last have your eyesight tested?
Please tick whether you are RIGHT
What is your height?
or LEFT
hand dominant?
What is your weight?
Do you receive any of the following payments?
Higher Rate Mobility Component. (Of DLA)
YES
NO
War Pensioners’ Mobility Supplement
YES
NO
Personal Independence Payment
YES
NO
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SECTION C: ABOUT YOU and YOUR MOBILITY.
Do you need to use any mobility or walking aids?
YES
NO
If YES please give us the details, If NO please go to SECTION D.
Mobility Aid Used
Make and Model
Walking Aids
Manual wheelchair:
Indoor
Outdoor
Crutches
Power Chair:
Indoor
Outdoor
Rollator
walker
Scooter:
Indoor
Walking stick(s)
Zimmer Frame
Outdoor
Can you walk or take a few steps? YES
NO
Can you stand without help?
NO
YES
/
wheeled
If you use a wheelchair, can you transfer into a vehicle without help from
others?
YES
NO
Are you able to load or transport your wheelchair in your vehicle without
help from anyone else?
YES
Does someone else load it for you?
NO
YES
NO
If yes please explain how they do this:
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SECTION D: ABOUT YOU and DRIVING (If you are applying for a
PASSENGER or HOIST ASSESSMENT, please go to SECTION E)
Do you have a driving licence?
YES
NO
If NO please contact the Mobility Centre for advice:
Tel 01872 254920
If YES, what type of licence do you have? (Please tick)
Full
Provisional
Revoked
Surrendered
Section 88 (You have applied to DVLA to renew your licence)
What is your Driver Number?
When does your licence expire?
Was your licence issued in the UK?
YES
NO
If NO where was your licence issued?
Have the DVLA been informed of your medical condition?
YES
NO
If yes, what date did you inform them?
Have you been advised to stop driving?
If yes, was this by (Please tick)
a doctor
Are you currently driving YES
NO
Have never driven
YES
NO
or the DVLA
If No please tell us if you:
Have had driving lessons in the past
Are currently having driving lessons
If you used to drive but stopped, what date did you stop?
Have you had any accidents recently?
YES
NO
If yes, please give details.
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SECTION E: ABOUT YOU and YOUR VEHICLE(S)
Do you currently have a vehicle?
If yes, what is the
YES
Make:
NO
Model:
And year of Manufacture:
What type of vehicle do you drive at present?
Manual Transmission
Automatic Transmission
Is your vehicle adapted in any way
YES
NO
If yes, please give details:
Is your vehicle on lease through Motability?
YES
NO
If yes, what is the renewal date?
Anything else you wish to add which may be relevant to your
assessment:
Please tell us how you heard about us:
Occasionally people cancel appointments at short notice. Would you like
us to tell you about last minute cancellations if it would mean an earlier
appointment?
YES
NO
Please tell us of any dates within the next two months that you would not
be able to attend for your assessment:
Do have any other special requirements (e.g. will you need
accommodation in or near the assessment location?) YES
If yes, can you please explain your requirements?
NO
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SECTION F: TYPES OF ASSESSMENT.
Please select which assessment type you feel best suits your needs.
If you are unsure which type of assessment you need please contact the centre,
and ask to speak to one of our driving assessors. Tel: 01872 254920

FULL DRIVING ASSESSMENT
If you have or have had an illness which may affect your ability to
continue to drive safely. This assessment looks at your ability to
control the vehicle and how you deal with traffic and other road
users. The cost of this assessment is £80

ADAPTATIONS ASSESSMENT
This assessment is for people who have a physical disability and
need advice on vehicle adaptations but who do not need to drive
from a wheelchair. This assessment will give you the opportunity to
try out equipment.
The cost of this assessment is £80

DRIVE FROM WHEELCHAIR ASSESSMENT
If you need to drive from a wheelchair because you cannot transfer
from your wheelchair or stow your wheelchair. This assessment will
give you the opportunity to try out a drive from wheelchair vehicle
and adapted driving controls.
The cost of this assessment is £140

PASSENGER TRANSFER AND SEATING ASSESSMENT
For passengers who have difficulty transferring from a wheelchair to
a vehicle. The cost of this assessment is £80

WHEELCHAIR OR SCOOTER HOIST ASSESSMENT
For people who need advice on the best method of getting a
wheelchair or scooter into and out of a vehicle. This assessment will
look at your standing ability, balance and ability to use equipment.
The cost of this assessment is £80

OFF-ROAD ASSESSMENT
For people who do not have driving entitlement. This assessment
can include a vision screen, a physical screen and if required
cognitive screen.
Please contact the centre to discuss your needs with a driving
assessor
SPECIALIST ASSESSMENT(S) FOR EMPLOYERS, SOLICITORS OR
INSURANCE COMPANIES:
Assessments which require a more complex assessment and a more
detailed report including court compliant reports are charged
accordingly.
Please contact us for full details and costs.
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Please tell us what you hope to achieve from this assessment?
Please tell us a bit about any difficulties you are experiencing as a driver
or passenger?
Has someone else suggested that you should have this assessment?
YES
NO
Are they paying for this assessment?
YES
NO
If yes, please give us their name and address.
Name:
Address:
Postcode:
Telephone Number:
Email address:
WHERE WOULD YOU LIKE TO HAVE YOUR ASSESSMENT? (Please tick)

Cornwall Mobility Centre, Truro

Plymouth

Holsworthy Hospital, Holsworthy, Devon (non-DVLA
referrals only)

Exeter

Echo Centre, Liskeard

West Cornwall Hospital, Penzance

Launceston General Hospital, Launceston
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SECTION G: PAYMENT
Please send your payment to us with this form (please see
page 6 for charges).
You can pay by Cheque, Debit or Credit card.
Cheque: Please make cheques payable to “Cornwall Mobility
Centre Ltd”.
Debit/Credit Card: Please complete the boxes below.
Card Type: (please tick)
Visa
Visa Electron
Mastercard
Switch
Solo
Name on card: (please print)
Please enter your card number below
Please enter the start date on your card (mm/yy) below
Please enter the expiry date on your card (mm/yy) below
Please enter the last 3 digits of the number printed over the signature
strip on your card below
Please enter your issue number (Switch only) below
Amount to be debited:
£
SIGNATURE:
DATE:
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CONSENT AND DECLARATION
Cornwall Mobility may need to use information about you for statistical
purposes. Any information used by Cornwall Mobility will be anonymised
and all information held will be treated as strictly confidential under the
terms of the Data Protection Act.
Cornwall Mobility may need to contact your GP, Consultant or other
healthcare professional for medical details to help us carry out your
assessment and may with your consent, send a copy of your assessment
report to your GP, the DVLA, Motability, your insurance company,
solicitor and any other person or organisation who referred you for the
assessment.
Be aware that in the case of a Driving Assessment you will be given
advice and information regarding your ability to drive.
Please sign below to indicate your consent for Cornwall Mobility to carry
out your assessment and to share the information about you as
described above.
NAME: (Please print)
SIGNATURE:
DATE:
If you are signing on behalf of the applicant please could you indicate
your relationship to them e.g. relative, legal Guardian etc.?
……………………………………………………………………………………………
On occasions, Cornwall Mobility may have health professionals or
Approved Driving Instructors who wish to observe an assessment
process for training purposes. If you do not wish to have an observer
attend your assessment, please tick the box.
Thank you for completing this application form. Please return
it by post to:
Cornwall Mobility, North Buildings, Royal Cornwall Hospital
Truro, TR1 3LJ.
Or by email to: [email protected]
If you have any problems completing the form or need any
further information, please telephone us on
01872 254920
Or email us at [email protected]
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