Driver Skills Self-Assessment Questionnaire

Hearing

With the car windows rolled up, can you hear a siren or horn?

Yes
No

Can you hear the sound of your turn signals when they are on?

Yes
No

Vision

Can you see objects clearly?

Yes
No

Can you see clearly at night?

Yes
No

Can you go outside in the bright sunlight and immediately see clearly?

Yes
No

NOTE: This does not pertain to going outside in the sunlight from a dark room.

Can you see clearly over the steering wheel?

Yes
No

Head and Neck

Can you turn your head an equal distance from one side to the other?

Yes
No

Can you turn your head and neck far enough to see over your shoulders?

Yes
No

Arms and Hands

Can you drive long distances without your hands and arms being tired?

Yes
No

Can you drive for a minimum of 30 minutes without your fingers or arms becoming tingly or numb?

Yes
No

Can you keep a firm, but comfortable grip on the steering wheel with both hands while keeping your elbows bent and relaxed?

Yes
No

Can you lift your arm high enough to adjust the rearview mirror?

Yes
No

Can you cross your hands one over the other when turning the steering wheel?

Yes
No

Legs and Feet

Can you depress the brake pedal with your knee bent?

Yes
No

Can you sit for 15 minutes without your feet or legs becoming tingly or numb?

Yes
No

Do you use only your right foot to depress either the gas or brake pedals?

Yes
No

Can you bend your foot at least 10 degrees?

Yes
No

Cognitive

Can you easily decide when to enter a lane of moving traffic?

Yes
No

Are you comfortable driving in intersections?

Yes
No

Are you calm while driving?

Yes
No

Do you have a clean driving record with no tickets or collisions?

Yes
No

Has a very close family member or friend said you are an excellent driver?

Yes
No

Can you remember how to get to familiar places?

Yes
No

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