OCCUPATIONAL THERAPY UNIT
KLINIK KESIHATAN BANDAR ALOR SETAR
OCCUPATIONAL THERAPY PRE – DRIVING
ASSESSMENT
To be completed by Occupational Therapist
License Type: Date:
Car Current
Motorcycle Not Licensed Driving Experience:
Others Cancelled/Suspended
Referred by:
Doctor
Road Transport Department
Others
Part I: Personal Data
Name: R/N: In/Out pt.:
Age: Gender: I/C No:
Marital Status:
Address:
Occupation: Contact No:
1
Part II: Medical Information
Diagnosis:
Problem statement:
Medication:
2
Part III: Clinical Assessment – Physical performance (functional issues relevant to driving)
1. Driving history
2. Vehicle driven
3. Mobility 4. Transfer in /out of car
Yes No Satisfactory
Unsatisfactory
Ambulant
Aids and
adaptation
5. Trunk and Neck Rotation
Motion Satisfactory Unsatisfactory
Rotate to Left
Rotate to Right
Neck rotation
. Physical Assessment
6
Physical Movement ROM STRENGTH PAIN
R L R L R L
Shoulder flexion
Shoulder extension
Shoulder abduction
Shoulder adduction
Elbow flexion
Elbow extension
Wrist extension
Wrist flexion
Hand grip
Hip flexion
Hip extension
Knee extension
Knee flexion
Ankle dorsiflexion
Ankle plantarflexion
3
7.0 Coordination
Eye to hand
Hand to hand
Eye to hand to leg
7.1 Trunk Balance
Static Dynamic
Sitting
Standing
7.2 Sensation: Note affected area
7.3 Hand Function: Please tick ( )
Hand Function Right Left
Dominant Hand
Fisting
Power Grip
Pinch Grip
Span
Abduction/Adduction
7. 4: Summary: Please tick ( )
UPPER LIMB LOWER LIMB
Right Left Right Left
Normal
Impaired but satisfactory for unmodified
driving function
Impaired but satisfactory for modified
driving function
Impaired but may contribute to driving
function intermittently
Impaired
4
Part IV: Perceptual and Cognitive Impairment
1.Visual-Perception
I. Shade in any areas of deficit. Right Left
Absent Impaired Intact
2. Visual Attention
3. Visual Scanning
4. Visual neglect
5. Right Left Discrimination
6. Figure Ground
7. Form Constancy
8. Position in space
9. Spatial relations
10. Dept and distance deficits
11. Visual object agnosia
Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
2. Cognitive
Impaired Normal
1. Problem solving
2. Judgement
3. Planning and organization
4. Decreased insight and impulsitivity
Comments:
______________________________________________________________________________________
______________________________________________________________________________________
5
3. Mental Status
MMSE Score
Orientation
Registration
Attention & Calculation
Recall
Language
Copying
Total /30
Part V: Driving Function – Car
1. Knowledge of Basic Vehicle Component:
Yes No
No. Component Yes No
1. To control and rotate steering wheel safely
2. Ability to control switches while driving :
a. Horn
b. Wipers
c. Turn signals
d. Head lamp
e. Air-cond
f. Radio/Cassette/CD
3. Gear shift
a. Manual transmission
b. Automatic transmission
4. Accelerator and brake
a. Ability to apply pressure on pedal
5. Ability to adjust car seat
6. Ability to adjust rear mirror
Comments:
__________________________________________________________________________________
6
Part VI: Motorcycle
No Component Yes No
1. Ability to balance on motorbike
2. Ability to change clutch
a. By foot
b. By hand
3. Ability to control motorbike while riding
a. On even road
b. On uneven road
c. Making turn
4. Ability to control switches while riding
a. Signal
b. Head Lamp
c. Horn
5. Ability to stop safely and put the stand
Comments:
___________________________________________________________________________________
Part VII: Recommendation
Car Motorcycle
Fit to take driving lesson
Not fit for taking driving lesson
Need further rehabilitation
7
Vehicular modification:
Car Motorcycle
SHIFTING GEAR: SHIFTING CLUTCH:
a) Floor manual a) Automatic (Scooter only)
b) Automatic b) Foot
c) Extended clutch c) Hand control
d) Extended hand control
ACCELERATOR: THROTTLE:
a) Hand control Right / Left a) Standard
b) Foot control Right / Left b) Hand control right
c) Foot control - extended c) Hand control left
BRAKE: BRAKE:
a) Standard a) Standard
b) Power b) Hand control right
c) Hand Control c) Hand control left
d) Hand Control - extended d) Foot control
e) Foot Control e) Hand control right and left
STEERING WHEEL: TYPE OF MOTORCYCLE:
a) Standard a) Scooter
b) Power b) Four stroke
c) Swivel Knob c) Two stroke
d) Palmar calf d) With side loader/pick-up
e) Amputee ring e) Additional two rear wheels
Other Recommendation:
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Occupational Therapist: _______________________________________________________________
Official stamp & Signature: _____________________________________________________________
8
Lampiran A
UNIT PEMULIHAN CARAKERJA
KLINIK KESIHATAN BANDAR ALOR SETAR
LAPORAN PENILAIAN PRA-MEMANDU
PENGESAHAN KELAYAKAN
Saya mengesahkan telah menilai pemohon bernama …...........................………………………………….............. .........
No K/P:………………………………………………….…..................... ........... dan mendapati pemohon ini:
Layak untuk memohon lessen memandu/atau terus memandu Tidak layak untuk memohon lesen
Memerlukan penilaian pemanduan semula Memerlukan program pemulihan
CADANGAN PENGUBAHSUAIAN KENDERAAN:
CAR MOTORCYCLE
SHIFTING GEAR SHIFTING CLUTCH
a)Floor manual a)Automatic (Scooter only)
b)Automatic b)Foot
c)Extended clutch c)Hand foot
d)Extended hand control
ACCELERATOR THROTTLE
a)Hand control right/left a)Standard
b)Foot control Right /Left b)Hand control right
c)Foot control extended c)Hand control left
BRAKE BRAKE
a)Standard a)Standard
b)Power b)Hand control right
c)Hand control c)Hand control left
d)Hand control extended d)Foot control
e)Foot control e)Hand control right and left
STEERING WHEEL TYPE OF MOTORCYCLE
a)Standard a)Scooter
b)Power b)Four stroke
c)Swivel Knob c)Two stroke
d)Palmar cuff d)With side loader/pick up
e)Amputee ring e)Additional two rear wheel
Cadangan lain jika ada: ...............…........………………………………………………………………..............................................
...............................................................................................................................................................................
Tandatangan / cop rasmi:…………………………………………………...… Tarikh:…………………………………
Pegawai / Jurupulih Carakerja:………………………………………………
