體格檢驗證明書(只適用於七十歲或以上申領或續領正式／暫准／臨時／學習駕駛執照的人士)______________________________________________________________________________________________
甲部 申請人資料(注意：本證明書的體格檢驗報告（乙部）必須於申請人提出執照申請前四個月內，由註冊醫生（請參閱丙部第(1)項）填寫及簽發。）
申請人姓名：____________________________

身分證明文件號碼：__________________________________________________________________________________________________________________________
乙部 體格檢驗報告 (必須由負責為上述申請人檢查身體的註冊醫生（請參閱丙部第(1)項）填寫及簽發）

註冊醫生在為申請人檢查身體前，請參閱下述事項：
香港法例第 374B 章《道路交通（駕駛執照）規例》訂明，年滿 70 歲或以上的人士在申領或續領正式駕駛執照／暫准駕駛執照／臨時駕駛執照／學習駕駛執照時，須連同申請表遞交一份由註冊醫生簽發的體格證明
書，證明他／她適宜駕駛其所申請類別的車輛。如運輸署署長認為該申請人患有下列所述的任何疾病或身體傷殘，則須拒絕向他／她發出駕駛執照或將其駕駛執照續期：

一. 癲癇症(另稱腦癇症)。
二. 高血壓或其他因由，以致有可能突然暈眩或昏倒以致失去能力。
三. 精神紊亂，以致執照申請人或持有人（視屬何情況而定）有可能根據《精神健康條例》（第 136 章）被羈留或以住院病人身分在該條例所指的精神病院接受治療。
四. 任何導致肌肉不受控制的狀況。
五. 未受控制的糖尿病。
六. 不能在白天充足光綫下讀出與他相距 23 米的登記號碼（有需要者在配戴眼鏡或其他矯正視力鏡片作為協助，仍不能讀出）。
七. 任何其他疾病或傷殘，而該疾病或傷殘很可能令申請人或執照持有人沒有能力在不危及公眾安全的情況下，有效地駕駛或控制該執照所指的汽車或經適當改裝的汽車；但失聰本身並不當作為上述的傷殘。

丙部第(2)項列出註冊醫生為申請人進行體格檢查時，可參照的有關檢查範圍。然而，註冊醫生可依據其專業
判斷，為申請人作出其他合適的檢查，藉以取得足夠參考資料，填寫以下的報告總結。

TD256 (9/2016)

完成體格檢驗後的總結經檢查申請人的體格後，我對申請人在體格方面是否適宜駕駛車輛的意見如下（請在以下適當方格內加上（9）號及填寫評語(如有））：□□

我認為上述申請人在體格方面適宜駕駛車輛，而對申請人在視力及聽覺方面的意見如下：
是否(1) 駕駛時須佩戴矯正視力之鏡片□□(2) 駕駛時須戴上助聽器□□

上述申請人在體格方面不適宜駕駛車輛，原因如下(如患有上文所述的任何疾病或身體傷殘，請清楚列明哪一項)：____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

其他評語(如有)：____________________________________________________________________________________________________________________________________________________________________________________________
聲明我已於______________________________(檢驗日期) 為上述申請人檢驗身體，並考慮了所有應該檢查的範
圍；而以上的體格檢驗報告是根據我的評估填寫。

簽發醫生姓名 : _________________________________ (請參閱丙部第(1)項)
簽發醫生簽署 : _________________________________
簽發日期: _________________________________

簽發醫生的聯絡電話號碼 : _______________________
簽發醫生的通訊地址

TD256 (9/2016): ______________________________________________________________________

______________________________________________________________________________________________
丙部 注意事項(1)

註冊醫生是指根據香港法例第 161 章《醫生註冊條例》正式註冊為香港醫務委員會註冊醫生或被當作已根據該條例註冊為醫生的人士。海外執業的醫生亦須符合香港法例第 161 章《醫生註冊條例》之註冊要求。

(2)

以下列出註冊醫生為申請人進行體格檢查時，建議可參照的檢查範圍。然而，下列建議檢查範圍未必涵蓋所有應檢查的範圍，有關註冊醫生應以其專業判斷，決定是否需要增加其他檢查項目。

視力：



是否患有任何眼疾或視力失調，以致在白晝光線下，不能讀出在距離二十三米處之車牌號碼駕駛時是否須佩戴眼鏡或其他矯正視力鏡片
是否一目失明或僅有單眼視力精神狀態：是否患有癲癇或其他痙攣病症
是否患有任何精神病，包括可能影響駕駛能力之中樞神經系統老年性變質或血管變質
是否有任何毒癖徵象
是否有可能影響精神狀態之任何藥療記錄
是否患有不受控制之糖尿病
是否有酒精中毒記錄

骨骼及肌肉系統：


是否患有骨骼、關節及肌肉之先天性變形

是否患有足以導致殘廢之任何類型關節炎



是否近期或過往曾患癱瘓

是否近期或過往曾嚴重受傷

平衡與協調：


是否患有足以導致突然發生失去活動能力之眩暈或昏倒之疾病或機能失調，例如耳病性眩暈，不受控制之高血壓、小腦疾病、嚴重貧血、心傳導阻滯或哮喘等

是否患有造成肌肉共濟失調或震顫之任何失調或疾病聽覺：

是否患有足以導致失聰或平衡紊亂之耳部疾患

其他：

是否患有任何慢性阻塞性氣道病



是否有任何類型之高血壓

是否有任何變質性或局部缺血性心臟病之徵象

是否近期或過往曾進行大手術



是否患有可能影響駕駛機動車輛能力之任何其他疾病

TD256 (9/2016)

(3)在接獲申請人遞交本體格檢驗報告後，運輸署或會向簽發本報告的註冊醫生核實內容，以便進一步考慮
申請人的駕駛執照申請。

______________________________________________________________________________________________丁部 關於你個人資料的事項
收集目的
1.
2.

運輸署會使用透過本表格所獲得申請人的個人資料，用作辦理在本表格中所述的申請的事宜。
你必須提供本表格所要求的個人資料。假如你未能提供所需資料，你的申請可能不獲接納。

獲轉交資料的部門／人士3.

你透過本表格所提供的個人資料會向其他政府部門、決策局及有關機構披露，以作上文第1項所述的用途。

索閱個人資料4.

根據個人資料（私穩）條例第 18 及 22 條及附表 1 第 6 條，你有權索閱及修正你的個人資料。你的索閱權包括獲取本表格所提供的個人資料副本一份。

查詢5.

有關透過本表格收集的個人資料的查詢，包括索閱及修正資料，應寄往：
香港
金鐘道 95 號統一中心 3 樓
牌照事務組
行政主任／首次登記稅收啟TD256 (9/2016)

Medical Examination Certificate(Only for Applicants Aged 70 or above for Issue or Renewal of Full/ Probationary/Temporary/ Learner’s Driving Licence)______________________________________________________________________________________________Part A Particulars of Applicant(Important: This medical examination report (Part B) must be issued within 4 months counted from the date ofapplication and must be completed and signed by a registered medical practitioner (see Note 1 in Part C))
Name of Applicant: ______________________________

Identity Document No. : ____________________________________________________________________________________________________________________________Part B Medical Examination Report (must be completed by a registered medical practitioner who conducts
the medical examination on the applicant. Please see Note 1 in Part C)
Before conducting the medical examination on the applicant for completion of this report, the registered
medical practitioner is requested to read the following:
According to the Road Traffic (Driving Licences) Regulations (Cap. 374B), any person aged 70 or above applying for
issue/ renewal of a full/ probationary/ temporary/ learner’s driving licence shall attach to his/ her application acertificate by a registered medical practitioner that he/ she is medically fit to drive and control any vehicle in the classwhich he/ she would be permitted to drive. If it appears to the Commissioner for Transport that the applicant issuffering from any of the following diseases or physical disabilities, the Commissioner for Transport shall refuse toissue/ renew the driving licence:
1. Epilepsy.
2. Liability to sudden attacks of disabling giddiness or fainting due to hypertension or any other cause.
3. Mental disorder for which the applicant for the licence, or, as the case may be, the holder of the licence is liable tobe detained under the Mental Health Ordinance (Cap. 136) or is receiving treatment as an in-patient in a mental
hospital within the meaning of that Ordinance.
4. Any condition causing muscular incoordination.
5. Uncontrolled diabetes mellitus.
6. Inability to read at a distance of 23 metres in good daylight (with the aid of spectacles or other corrective lenses, ifworn) a registration mark.
7. Any other disease or disability which is likely to render him/ her incapable of effectively driving and controlling a
motor vehicle or suitably adapted motor vehicle to which such licence refers without endangering public safety,
provided that deafness shall not of itself be deemed to be any such disability.
Note 2 in Part C suggests areas which the registered medical practitioner may have to consider during the medical
examination. The registered medical practitioner may conduct, based on his professional judgment, any test which
he thinks appropriate to facilitate his conclusion in the ensuing paragraph.

TD256 (9/2016)

Conclusion after Conducting the Medical Examination
After conducting the medical examination, I consider that the applicant’s fitness to drive motor vehicles is as follows(please tick (9) in the appropriate box(es) and provide your views, if any):□The above-named person is medically fit to drive motor vehicles and my opinion on his/ her visual and acoustic
ability is as follows:□Yes

No( 1 ) he/ she needs to wear corrective lenses while driving□□( 2 ) he/ she needs to wear hearing aids while driving□□

The above-named person is not medically fit to drive motor vehicles for the following reason(s) (please specify
which item if he/ she is suffering from any of the above-mentioned diseases/ physical disabilities):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Other Remarks (if any):____________________________________________________________________________________________________________________________________________________________________________________________
Declaration
I have conducted a medical examination on _____________________ (date) with the applicant, and considered all therelevant areas needed to be assessed. This medical report is completed by me according to my assessment.
Name of the Registered
Medical Practitioner(Please see Note 1 in Part C)：________________________________________________________________(IN BLOCK LETTERS)

Signature of the Registered
Medical Practitioner：________________________________________________________________

Date of Issue：________________________________________________________________

Contact Telephone Number：________________________________________________________________

Correspondence Address：________________________________________________________________________________________________________________________________

TD256 (9/2016)

______________________________________________________________________________________________Part C Important Notes(1)

Registered medical practitioner means a person duly registered as a medical practitioner of the Medical
Council of Hong Kong, or deemed to be registered as a medical practitioner under the Medical Registration
Ordinance (Cap. 161). Overseas medical practitioner shall also comply with the registration requirement
under the Medical Registration Ordinance (Cap. 161).

(2)

When conducting the medical examination, the registered medical practitioner is suggested to take into
account the following areas. The list may not be exhaustive, and the registered medical practitioner may
exercise his professional judgment to include whatever test on the applicant as necessary.
Eyes-sight:

Whether he/ she has any eye disease or disorder that will lead to inability to read at a distance of 23
metres in good daylight a registration mark

Whether he/ she needs to wear spectacles or other corrective lenses while driving



Whether he/ she has loss of one eye or monocular vision

Mental State:

Whether he/ she is suffering from epilepsy or other convulsive disorderWhether he/ she is suffering from mental disorder including senile or vascular degeneration of thecentral nervous system which may affect his/ her fitness to driveWhether he/ she has any sign of drug addictionWhether he/ she has any history of medication that may affect his/ her mental stateWhether he/ she is suffering from uncontrolled diabetes mellitus

Whether he/ she has any history of alcoholism

Skeletal and Muscular System:

Whether he/ she is suffering from deformity of bones and joints and muscles

Whether he/ she is suffering from any form of crippling arthritis



Whether he/ she has suffered from paralysis

Whether he/ she has suffered from severe injury

Balance and Coordination:


Whether he/ she is suffering from disease or disorders leading to sudden attacks of disabling giddinessor fainting such as Meniere’s Disease, uncontrolled hypertension, cerebellar disorder, severe anaemia,
heart-block and asthmaWhether he/ she is suffering from disorder or diseases causing muscular incoordination or tremour

TD256 (9/2016)

Hearing:Whether he/ she is suffering from disorders or diseases of the ear leading to deafness or disturbance ofbalance

Others:

Whether he/ she is suffering from chronic obstructive airway diseaseWhether he/ she is suffering from hypertension

Whether he/ she is sign of degenerative or ischaemic heart diseaseWhether he/ she has taken major surgery



Whether he/ she is suffering from any other disease that may affect the efficiency of driving a motorvehicle(3)

Transport Department may seek confirmation from the registered medical practitioner completing this report
whilst considering the driving licence application, after receiving this report from the applicant.

______________________________________________________________________________________________Part D Notes about Your Personal Data
Purposes of Collection
1.

The personal data provided in this form will be used by the Transport Department for processing theapplication.

2.

You must provide the personal data as required. Otherwise, the application may be refused.

Classes of Transferees
3.

The personal data you provided in this form may be disclosed to other Government departments, bureaux andrelevant organizations for the purposes mentioned in paragraph 1 above.

Access to Personal Data
4.

You have the right of access and correction to your personal data as provided according to sections 18 and 22
and principle 6 of Schedule 1 of the Personal Data (Privacy) Ordinance. Your right of access includes
obtaining a copy of your personal data provided in this form.

Enquiries
5.

Enquiries concerning the personal data collected through this form, including access and corrections, should besent to:
Executive Officer/FRT
Licensing Section
3/F, United Centre
95 Queensway
Hong Kong

TD256 (9/2016)