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154 A p p e n d i x G Medical Conditions and Medications Survey and Medical Conditions and Medications Exit Survey
155 Medical Conditions & Medications There are 38 questions in this survey General Information 1 Note: 4 ft = 48 inches; 5 ft = 60 inches; 6 ft = 72 inches Please write your answer(s) here: Height (inches): Weight (lbs): Neck Size (inches): If you do not know your neck size enter "0" Instructions 2 Instructions: Below is a list of medical conditions, diseases, and medications that may affect driving. For each condition, check Yes or No. Only choose Yes for recent conditions as follows: If you were treated for the condition within the past year (e.g., a doctor's office visit, hospitalization, or surgery), OR If you are currently on medication for the condition OR If you are using an aid related to the condition (e.g., corrective lenses, a hearing aid, or a cane) OR Currently active health condition.
156 Vision Conditions 3 Check all that apply: Please choose all that apply: Objects far away are blurry when not wearing corrective lenses (e.g., nearsighted). Objects close up are blurry when not wearing corrective lenses (e.g., farsighted). Astigmatism Reading glasses needed Glaucoma Color blindness Blind in one eye Poor night vision Detached retina Tunnel (no peripheral) vision Lasik or similar surgery 4 Other vision conditions Please choose only one of the following: Yes No Make a comment on your choice here:
157 5 Please select one of the following to describe your use of vision correction aids: Please choose only one of the following: I do not use glasses or contact lenses I use glasses for reading only I use glasses for driving and similar activities only I wear glasses most of the time I wear contact lenses 6 If you wear corrective lenses while driving, they are: Please choose only one of the following: Standard Bifocal Trifocal Progressive lenses
158 Hearing Conditions 7 Check all that apply: Please choose all that apply: Difficulty hearing, but no hearing aid Hearing aid Deafness 8 Other hearing conditions Please choose only one of the following: Yes No Make a comment on your choice here:
159 Heart Conditions 9 Check all that apply: Please choose all that apply: Angina Angioplasty Heart attack Bypass surgery Pacemaker Congestive heart failure Hypertension (high blood pressure) Hypotension (low blood pressure) 10 Other heart conditions Please choose only one of the following: Yes No Make a comment on your choice here:
160 Stroke and Similar Brain Conditions 11 Check all that apply: Please choose all that apply: Stroke TIA (mini-stroke) Brain aneurysm Brain hemorrhage Brain surgery Traumatic brain injury 12 Other brain conditions Please choose only one of the following: Yes No Make a comment on your choice here:
161 Vascular (Blood Vessel) Conditions 13 Check all that apply: Please choose all that apply: Peripheral aneurysm (in legs, arms, hands, or feet) Aortic aneurysms Deep-vein thrombosis (blood clot) 14 Other vascular conditions Please choose only one of the following: Yes No Make a comment on your choice here:
162 Nervous System and Sleep Conditions 15 Check all that apply: Please choose all that apply: Epilepsy Narcolepsy Sleep apnea Insomnia Restless Leg Syndrome Shift Work Disorder Periodic Limb Movement Disorder Parkinson's Disease Multiple Sclerosis Migraines Dizziness Brain tumors Peripheral Neuropathy (numbness and tingling in hands, feet, arms, and legs) 16 Other nervous system conditions Please choose only one of the following: Yes No Make a comment on your choice here:
163 Respiratory Conditions 17 Check all that apply: Please choose all that apply: Asthma Chronic Obstructive Pulmonary Disease (COPD) 18 Other respiratory conditions Please choose only one of the following: Yes No Make a comment on your choice here:
164 Diabetes and Other Metabolic Conditions 19 Check all that apply: Please choose all that apply: Type 1: Insulin dependent Type 2: Non-insulin dependent Type 2: Insulin dependent Hyperthyroidism Hypothyroidism 20 Other metabolic conditions Please choose only one of the following: Yes No Make a comment on your choice here:
165 Kidney Conditions 21 Chronic kidney failure Please choose only one of the following: Yes No 22 Other kidney conditions Please choose only one of the following: Yes No Make a comment on your choice here:
166 Musculoskeletal (Muscle and Bone) Conditions 23 Limited flexibility (e.g., difficulty checking blind spots) Please choose only one of the following: Yes No Make a comment on your choice here: 24 Severe Arthritis Please choose only one of the following: Yes No Make a comment on your choice here:
167 25 Artificial limbs Please choose only one of the following: Yes No Make a comment on your choice here: 26 Paralysis Please choose only one of the following: Yes No Make a comment on your choice here:
168 27 Muscle and movement disorders Please choose only one of the following: Yes No Make a comment on your choice here: 28 Other musculoskeletal conditions Please choose only one of the following: Yes No Make a comment on your choice here:
169 29 Which of the following do you use on a regular basis? Please choose all that apply: Crutches Cane Walker Wheelchair Other
170 Cancer 30 Cancer Please choose only one of the following: Yes No Make a comment on your choice here:
171 Psychiatric Conditions 31 Check all that apply: Please choose all that apply: Anxiety or panic attacks Depression ADD / ADHD / Tourette's Syndrome Personality disorders Psychotic disorders Bipolar disorder 32 Other psychiatric conditions Please choose only one of the following: Yes No Make a comment on your choice here:
172 Current Medications Many medications can affect driving. Please indicate which medications you are currently taking (generic or brand name, dosage, and frequency) in the space below, one line per medication. Please include all over the counter medications as well as vitamins and supplements. For your convenience, a list of the top 300 medications can be found at the following website http://www.rxlist.com/script/main/art.asp?articlekey=79510 Examples: Ibuprofen, 400 mg, twice per day Levothyroxine Sodium (Synthroid), 0.15 mg, once per day 33 List your presently Prescribed Medications Please write your answer here:
173 Multiple Medical Conditions and Medications 34 I have been informed by a doctor in the past year that my multiple medical conditions may affect my ability to drive. Please choose only one of the following: Yes No 35 I have been informed by a doctor in the past year that my multiple medications may affect my ability to drive. Please choose only one of the following: Yes No 36 I have been informed by a doctor in the past year that my age-related medical conditions may affect my ability to drive. Please choose only one of the following: Yes No
174 37 I have had to give up driving for a period of time at some point in the past due to health issues (examples: injury, epilepsy, pregnancy, cancer, narcolepsy). Please choose only one of the following: Yes No Make a comment on your choice here:
175 Other Medical Issues or Concerns 38 Are there any other medical issues or concerns not reflected above that may affect your driving? Please choose only one of the following: Yes No Make a comment on your choice here: Submit Your Survey. Thank you for completing this survey.
176 Medical Conditions & Medications - EXIT Survey There are 40 questions in this survey General Information 1 Age: Please write your answer here: 2 Gender: Please choose only one of the following: Female Male 3 Note: 4 ft = 48 inches; 5 ft = 60 inches; 6 ft = 72 inches Please write your answer(s) here: Height (inches): Weight (lbs): Neck Size (inches): If you do not know your neck size enter "0"
177 Instructions 4 Instructions: Below is a list of medical conditions, diseases, and medications that may affect driving. For each condition, check Yes or No. Only choose Yes for recent conditions as follows: If you were treated for the condition within the past year (e.g., a doctor's office visit, hospitalization, or surgery), OR If you are currently on medication for the condition OR If you are using an aid related to the condition (e.g., corrective lenses, a hearing aid, or a cane) OR Currently active health condition.
178 Vision Conditions 5 Check all that apply: Please choose all that apply: Objects far away are blurry when not wearing corrective lenses (e.g., nearsighted). Objects close up are blurry when not wearing correective lenses (e.g., farsighted). Astigmatism Reading glasses needed Glaucoma Color blindness Blind in one eye Poor night vision Detached retina Tunnel (no peripheral) vision Lasik or similar surgery 6 Other vision conditions Please choose only one of the following: Yes No Make a comment on your choice here:
179 7 Please select one of the following to describe your use of vision correction aids: Please choose only one of the following: I do not use glasses or contact lenses I use glasses for reading only I use glasses for driving and similar activities only I wear glasses most of the time I wear contact lenses 8 If you wear corrective lenses while driving, they are: Please choose only one of the following: Standard Bifocal Trifocal Progressive lenses
180 Hearing Conditions 9 Check all that apply: Please choose all that apply: Difficulty hearing, but no hearing aid Hearing aid Deafness 10 Other hearing conditions Please choose only one of the following: Yes No Make a comment on your choice here:
181 Heart Conditions 11 Check all that apply: Please choose all that apply: Angina Angioplasty Heart attack Bypass surgery Pacemaker Congestive heart failure Hypertension (high blood pressure) Hypotension (low blood pressure) 12 Other heart conditions Please choose only one of the following: Yes No Make a comment on your choice here:
182 Stroke and Similar Brain Conditions 13 Check all that apply: Pl Stroke TIA (mini-stroke) Brain aneurysm Brain hemorrhage Brain surgery Traumatic brain injury 14 Other brain conditions Yes No Make a comment on your choice here: ease choose all that apply: Please choose only one of the following:
183 Vascular (Blood Vessel) Conditions 15 Check all that apply: Peripheral aneurysm (in legs, arms, hands, or feet) Aortic aneurysms Deep-vein thrombosis (blood clot) 16 Other vascular conditions Yes No Make a comment on your choice here: Please choose all that apply: Please choose only one of the following:
184 Nervous System and Sleep Conditions 17 Check all that apply: Please choose all that apply: Epilepsy Narcolepsy Sleep apnea Insomnia Restless Leg Syndrome Shift Work Disorder Periodic Limb Movement Disorder Parkinson's Disease Multiple Sclerosis Migraines Dizziness Brain tumors Peripheral Neuropathy (numbness and tingling in hands, feet, arms, and legs) 18 Other nervous system conditions Please choose only one of the following: Yes No Make a comment on your choice here:
185 Respiratory Conditions 19 Check all that apply: Please choose all that apply: Asthma Chronic Obstructive Pulmonary Disease (COPD) 20 Other respiratory conditions Please choose only one of the following: Yes No Make a comment on your choice here:
186 Diabetes and Other Metabolic Conditions 21 Check all that apply: Please choose all that apply: Type 1: Insulin dependent Type 2: Non-insulin dependent Type 2: Insulin dependent Hyperthyroidism Hypothyroidism 22 Other metabolic conditions Please choose only one of the following: Yes No Make a comment on your choice here:
187 Kidney Conditions 23 Chronic kidney failure Please choose only one of the following: Yes No 24 Other kidney conditions Please choose only one of the following: Yes No Make a comment on your choice here:
188 Musculoskeletal (Muscle and Bone) Conditions 25 Limited flexibility (e.g., difficulty checking blind spots) Please choose only one of the following: Yes No Make a comment on your choice here: 26 Severe Arthritis Please choose only one of the following: Yes No Make a comment on your choice here:
189 27 Artificial limbs Please choose only one of the following: Yes No Make a comment on your choice here: 28 Paralysis Please choose only one of the following: Yes No Make a comment on your choice here:
190 29 Muscle and movement disorders Please choose only one of the following: Yes No Make a comment on your choice here: 30 Other musculoskeletal conditions Please choose only one of the following: Yes No Make a comment on your choice here:
191 31 Which of the following do you use on a regular basis? Please choose all that apply: Crutches Cane Walker Wheelchair Other
192 Cancer 32 Cancer Please choose only one of the following: Yes No Make a comment on your choice here:
193 Psychiatric Conditions 33 Check all that apply: Please choose all that apply: Anxiety or panic attacks Depression ADD / ADHD / Tourette's Syndrome Personality disorders Psychotic disorders Bipolar disorder 34 Other psychiatric conditions Please choose only one of the following: Yes No Make a comment on your choice here:
194 Current Medications Many medications can affect driving. Please indicate which medications you are currently taking (generic or brand name, dosage, and frequency) in the space below, one line per medication. Please include all over the counter medications as well as vitamins and supplements. For your convenience, a list of the top 300 medications can be found at the following website http://www.rxlist.com/script/main/art.asp?articlekey=79510 Examples: Ibuprofen, 400 mg, twice per day Levothyroxine Sodium (Synthroid), 0.15 mg, once per day 35 List your presently Prescribed Medications Please write your answer here:
195 Multiple Medical Conditions and Medications 36 I have been informed by a doctor in the past year that my multiple medical conditions may affect my ability to drive. Please choose only one of the following: Yes No 37 I have been informed by a doctor in the past year that my multiple medications may affect my ability to drive. Please choose only one of the following: Yes No 38 I have been informed by a doctor in the past year that my age-related medical conditions may affect my ability to drive. Please choose only one of the following: Yes No
196 39 I have had to give up driving for a period of time at some point in the past due to health issues (examples: injury, epilepsy, pregnancy, cancer, narcolepsy). Please choose only one of the following: Yes No Make a comment on your choice here:
197 Other Medical Issues or Concerns 40 Are there any other medical issues or concerns not reflected above that may affect your driving? Please choose only one of the following: Yes No Make a comment on your choice here: Submit Your Survey. Thank you for completing this survey.
