Notum

Driver's health declaration (Vairuotojo garbės deklaracija)

Save time during your visit — you can submit the questionnaire in advance.

Your details

Reason

A. Do you have any illness, disability or other medical complaint that could affect your ability to drive a motor vehicle?

1. Do you have any vision disorders, such as:

1.1. reduced vision
1.2. involuntary eye movements (nystagmus)
1.3. visual field defects (e.g. limited side vision)
1.4. double vision (diplopia)
1.5. noticeably worse vision at dusk or in the dark (night blindness)
1.6. reduced eye mobility
1.7. sensitivity to glare
1.8. impaired judgement of distance
1.9. other disorders (eye pain, sudden loss of vision, raised intraocular pressure diagnosed in the past or now, etc.)
2. Have you had or do you have dizziness?
3. Do you have impaired hearing, or have you had ear diseases?
4. Do you have impaired movement of your limbs, or any illness related to it?

5. Have you had or do you have heart and / or cardiovascular diseases:

5.1. stroke (paralysis)
5.2. heart rhythm disorders
5.3. heart attack or angina pectoris
5.4. congenital or acquired heart disease
5.5. other heart or cardiovascular disease (rheumatic fever, etc.)
6. Do you have diabetes?
7. Have you had a brain injury?
8. Have you had or do you have epilepsy?
9. Do you have, or have you ever had, significant balance disorders?
10. Have you fainted or do you faint, or have you had or do you have other disturbances of consciousness?
11. Do you have, or have you had, urinary disorders or impaired kidney function?
12. Do you have problems with attention, alertness, thinking or memory?

13. Do you have sleep disorders:

13.1. Do you feel tired or sleepy during the day?
13.2. Do you have involuntary attacks of sleep?
14. Do you misuse, or have you misused in the last 5 years, alcohol, tobacco, drugs or medicines?
15. Do you have, or have you had in the last 5 years, any mental disorder or mental illness, or have you been treated by a psychiatrist for it?

B. Questions about treatment, medication, etc.

16. Have you been treated in hospital or seen a doctor for any of the reasons above (A 1–15)?
17. Are you currently taking medicines prescribed by a doctor (sedatives, sleeping pills, painkillers or others)?
18. Have you been prescribed any medicines for one of the conditions above (A 1–13) that must be taken regularly over a long period?
19. Has your health been checked before for a driving licence?
20. Is your capacity for work limited because of an illness or a health problem?
21. Do you consider yourself completely healthy now?