Yes

No

Question

Do you experience increased anxiety when driving?

Have you gotten lost in familiar places?

Do you have difficulty noticing traffic signs?

Do you have identified vision problems, such as macular degeneration, glaucoma, or contrast sensitivity?

Do you experience confusion on exit or entrance ramps?

Have you ever moved into the wrong lane or gone the wrong way down a one-way street?

Do you have difficulty determining which turn signal to use when turning?

Do you ever confuse the brake and gas pedals, or have difficulty using them?

Have you experienced difficulty reacting quickly [to stop] when someone pulls out in front of you, or if an object or animal were in the road?

Have you recently hit curbs when parking?

Do you have trouble navigating turns?

Have you noticed scrapes or dents on the car, garage, or mail box?

Have you had “close calls” when driving?

Have you been in any recent accidents?

Have you recently received a ticket for a driving violation?

Do family members often express concern with your capacity to drive, or refuse to get in the car when you are the one driving?