Are you able to meet the legal eyesight standards for driving a car (with glasses or contact lenses, if normally worn)?:
Yes No Don't Know

Will to be able to climb the short distance from the ground to the footplate by ladder?:
Yes No Don't Know

Do you have Diabetes needing Insulin?:
No Yes Don't Know

Have you ever had Blackouts, fits, epilepsy, fainting attacks, recurrent dizziness, or any condition which may cause collapse or incapacity?:
No Yes Don't Know

Do you get discomfort or pain in the chest, or shortness of breath when exercising – eg when climbing a short flight of stairs?:
No Yes Don't Know

Do you have any difficulty in moving rapidly over short distances, including on slopes, steps or rough ground?:
No Yes Don't Know

Would you have difficulty in looking over either shoulder?:
No Yes Don't Know

Do you have any difficulty hearing a normal conversation (with hearing aid(s) if normally used?):
No Yes Don't Know

Do you have any other impairment of ability to communicate effectively?:
No Yes Don't Know

Are you taking medication that could give you dizziness or drowsiness?:
No Yes Don't Know

Have you used drugs of abuse (not including alcohol or tobacco) or other substance abuse within the last 12 months?:
No Yes Don't Know

Have you had any illness related to alcohol in the last 12 months?:
No Yes Don't Know

Do you suffer from any mental or nervous disorder (incl. ‘nerves’)?:
No Yes Don't Know

Do you have difficulty with or reduction in attention or concentration?:
No Yes Don't Know

Has any doctor advised you to refrain from any work or other activity because of a medical condition, or because of any medication you are taking?:
No Yes Don't Know

Have you been diagnosed with dementia or been tested for the condition?:
No Yes Don't Know

Do you use hearing aid(s) and wear them at all times during any activities?:
No Yes Don't Know