Datasets:

pdf2dataset

/

8e92ccd8c6ed05be00ad05065a30b2b0

like 0

12 of 12F-Declaration-to be completed by Medical Practitioner carrying out the examination Please ensure all sections of the form have been completed. Failure to do so will result in the form being invalid. At the time of the physical examination and completion of this medical form, I had possession of the individual's full medical records. Yes No Where 'No', please state your reason(s) why: Examining doctor's details To be completed by the doctor. Please print name and address in capital letters Practice Name Address Phone I confirm that this report was completed by me at the physical examination and that I am currently GMC registered and licensed to practice in the UK. GP's signature Surgery Stamp GMC Registration number Date DD M MYYYY Name (BLOCK CAPITALS) Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 1 June 18Restricted when completed TPH/204 V7. 0, 04/06/2018 1 of 12Transport for London London Taxi and Private Hire TPH/204 Medical Declaration TM004291 TPH/204 Medical Declaration Form Part 1 June 18 MAYOR OF LONDONTransport for London (Tf L), the Licensing Authority, needs to be satisfied that all licensed London taxi and Private Hire vehicle drivers are medically fit. In assessing an individual's medical fitness, Tf L has decided to be guided by the DVLA Group 2 standards. This form should be taken to a registered medical practitioner who has access toyour full medical records, typically your GP, for completion. If it is not completed by processing of your application. It is your responsibility to ensure that all your This medical report is for the confidential use of Tf L. This medical report cannot be issued free of charge as part of the National Health Service. The applicant must pay the medical practitioner's fee, unless other arrangements have been made. If you possess a valid DVLA Group 2 licence or are already licensed by Tf L as either a taxi or PHV driver and are now applying for the other licence, you do not need to have this form completed, unless this form has been requested to confirm your age related fitness. You are required to declare all medical conditions to the registered practitioner for the purpose of assessing your fitness to On completion, this form should be returned to: TFL London Taxi & Private Hire PO Box 177 Sheffield S98 1JY Further information may be requested from you should it be required in order to determine your Tf L recommends that all individuals take a photocopy of this form once it is completed for their own record before submitting the original. v7. 0Restricted when completed Yes No Where 'No', please confirm how you accessed the individual's full medical records:Are you the individual's registered NHS GP? medical conditions (if any) are declared to the medical practitioner completing this form. Please be aware that you will be required to undergo a physical examinationsomeone who has access to your full medical records this could lead to delays in the This page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date whilst this form is being completed. Tf L accepts no liability to pay it. hold a taxi or PHV Driver licence. medical fitness. TM004291 PT1 (Proof 5) Front Black Cyan Magenta Y ellow

2 of 12A-Personal Details B-Registered NHS GP Details A1 Surname A2 Forename(s) A3 Date of Birth DD M MYYYY A4 Current Address Postcode Rest of address B1 Name of Registered NHS GP B2 Address Postcode Premises number Rest of address TM004291 TPH/204 Medical Declaration Form Part 1 June 18This page is to be f ully completed by Applicant/Drive r 11 of 12E-Further Details Please use the space below to provide further, legible details required with reference to any of the previously answered questions. Please include relevant dates. It will be necessary to consult the DVLA's publication 'Assessing fitness to drive: a guide for medical professionals' and provide information as per Group 2 standards of fitness. https://www. gov. uk/guidance/assessing-fitness-to-drive-a-guide-for-medical-professionals Please continue on a separate sheet If required. Any additional sheets must be endorsed with the medical practitioner's signature, stamp and date. GP's signature Surgery Stamp Date DD M MYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 1 June 18Restricted when completed Restricted when completed This page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date TM004291 PT1 (Proof 5) Reverse Black Cyan Magenta Yellow

10 of 128 Psychiatric Does the applicant have a history of: Yes No (a) Psychiatric Disorder (b) Psychotic Illness (c) Dementia/Cognitive Impairment (d) Alcohol Misuse (e) Alcohol Dependency (f) Drug or Substance Misuse (g) Drug or Substance Dependency 9Any other conditions Yes No (a) Does the applicant named in section A suffer from any recognised medical condition (such as severe asthma, allergic reaction or chronic phobia) that would preclude them from carrying Guide and/or Assistance dogs? If YES, please request form TPH/208, which must be completed by a Specialist in the field that you require exemption. Yes No (b) (i) Does the applicant suffer from any other disease or disability that has not been previously mentioned? Yes No (ii) Is this likely to interfere with the efficient discharge of his or her duties as a vocational driver, or to cause driving by him or her to be a source of danger to the public? If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. GP's signature Surgery Stamp Date DD M MYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 2 June18Restricted when completed 3 of 12C-Applicant/Driver Consent and Declaration Privacy Notice Transport for London (Tf L) its subsidiaries and service providers will use your personal information (including any references to your health, ethnic origin, nationality, or previous criminal convictions), for the purpose of assessing your application, administering the licensing regime and equal opportunities monitoring. We will also provide you with information relating to the licensing and regulation of taxi and private hire services in London. Your personal information will be properly safeguarded and processed in accordance with the requirements of privacy and data protection legislation. Your name, badge/licence number and the status, start/expiry date of your licence may be made available on request or on a register for public inspection. If you have licensed a vehicle; the vehicle registration mark, licence number and expiry date may also be made available in the same way. We may share your information with, or receive information from, the Driver and Vehicle Licensing Agency (DVLA), Home Office Immigration Enforcement, Department for Work and Pensions (DWP), Motor Insurer's Bureau (MIB), Driver and Vehicle Standards Agency (DVSA), local authorities and other relevant organisations, including private hire operators, for the purposes of assessing your application or continuing fitness to hold a licence. In certain circumstances, Tf L may also share your personal information with the police and other agencies for the purposes of the prevention and detection of crime. For more information see www. tfl. gov. uk/privacy Consent and Declaration I hereby consent to Transport for London (Tf L) and their medical advisers processing personal data relating to my medical conditions for the purpose of assessing my fitness to hold a taxi or PHV Driver licence. I also give consent for my doctors and specialists to provide Tf L with any data they require in relation to this application. Signature Date DD M MYYYY TM004291 TPH/204 Medical Declaration Form Part 2 June 18Restricted when completed I declare that all information provided on this medical form is true and correct to the best of my knowledge. I understand that the issue of a licence in respect of this medical can be refused and any licence can be revoked if any statements aresubsequently found to be false. I undertake to keep Tf L informed of any changes to any details supplied in this form, and I am aware that failure to do so will constitute a breach of my licence condition and may lead to the possible revocation and suspension of my licence.-This page must be endorsed with applicants/driver's name, examining doctor's signature, surgery stamp and date TM004291 PT2 (Proof 5) Front Black Cyan Magenta Yellow

4 of 12Tf L recommends that all individuals take a photocopy of this form once it is completed for their own record before submitting the original. D-Medical Conditions-to be completed by Medical Practitioner Sections D-F must be completed by a Medical Practitioner who should:-Have access to the individual's full medical records.- Conduct a physical examination in person when completing this form.-Each page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date.-Answer all the relevant questions and provide copies of any reports.-Consult the DVLA's publication 'Assessing fitness to drive: A guide for medical professionals' https://www. gov. uk/guidance/assessing-fitness-to-drive-a-guide-for-medical-professionals Regulations state that taxi and PHV drivers must satisfy Tf L that they are medically fit to hold a driver's licence. In assessing whether an applicant is medically fit, Tf L will have regard to the medical standard that would apply in relation to a DVLA Group 2 licence. If you answer 'Yes' to ANY of the questions on this medical form, you must consult the DVLA's publication 'Assessing fitness to drive: a guide for medical professionals' and provide ALL the relevant information required for the condition(s) in accordance with the requirements of a Group 2 licence entitlement. TM004291 TPH/204 Medical Declaration Form Part 2 June 18Restricted when completed 9 of 127Vision Important information for doctors Please read the information below. In order to complete the following questions you may wish to refer the applicant to an optician or optometrist to ensure all questions can be answered accurately. Requirements Q a visual acuity of at least 6/7. 5 (decimal Snellen equivalent 0. 8) in the better eye Q a visual acuity of at least 6/60 (decimal Snellen equivalent 0. 1) in the other eye Q this may be achieved with or without glasses or contact lenses Q 3 metre readings must be converted to the 6 metre equivalent Q If glasses are worn (not contact lenses) to meet the minimum standards, they should have a corrective power of < + 8 dioptres. Q Complete loss of vision in one eye is a bar to licensing Uncorrected Visual Acuity Corrected Visual Acuity Prescription Left 6/ 6/ Right 6/ 6/ Yes No (a) Does the applicant use corrective lens? If Yes, glasses contact Lenses both together No Yes (b) Does the applicant have a normal binocular field of vision? Yes No (c) Does the applicant have uncontrolled diplopia? Yes No (d) Does the applicant have any other ophthalmic condition? Date DD M MYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291TPH/204 Medical Declaration Form Part 2 June 18Restricted when completed- Write inside the boxes-use BLOCK CAPITAL letters and black ink.- If you make a mistake, please cross it out (initial it) and write the correct information underneath.-Do not use correction fluid-Ensure that a response is provided for every question, unless specifically directed to the contrary. This page must be endorsed with applicant/driver's name, examining doctors's/optician's signature, surgery/optician stamp and date GP s/Optician s signature' ' GP s/Optician s stamp' ' TM004291 PT2 (Proof 5) Reverse Black Cyan Magenta Yellow

8 of 126Neurological Does the applicant have a history of: Yes No (a) Seizure/Epileptic attack and/or having taken anti-convulsant/epileptic medication in the last 10 years (b) A first unprovoked epileptic seizure/solitary fit within the last 5 years (c) Blackout/Impairment of Consciousness (d) Stroke/TIA If 'Yes', please give the date and complete ALL the questions below: DDDDMMMMYYYYYYYY (i) Has there been a full recovery? (ii) Is there any debarring residual impairment that would affect safe driving? (iii) Any other significant risk factors? (iv) Is there any imaging evidence of less than 50% carotid atery stenois? (v) Has exercise/functional testing been undertaken? If 'Yes', please ensure you complete question 3 of this form (on page 4) (e) Sudden Disabling Dizziness/Vertigo (f) Pathological Sleep Disorder (g) Chronic and/or Progressive Neurological Disorder (h) Brain Surgery (i) Traumatic Brain Injury (j) Brain Tumour If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. GP's signature Surgery Stamp Date DDDDMMMMYYYYYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 3 June 18Restricted when completed 5 of 121 Cardiovascular disease/procedure Does the applicant have a history of: Yes No (a) Acute Coronary Syndrome including Myocardial infarction If 'Yes', please provide date(s): DDDDMMMMYYYYYYYY (b) Coronary artery by-pass graft (CABG) If 'Yes', please provide date(s): DDDDMMMMYYYYYYYY (c) Percutaneous Coronary Intervention (P. C. I,) (Angioplasty) If 'Yes', please give date of most recent intervention: DDDDMMMMYYYYYYYY (d) Angina If 'Yes', please give date of the last know attack: DDDDMMMMYYYYYYYY (e) Heart failure (f) Implantable Cardioverter Defibrillator (ICD) (g) Cardiac Pacemaker (h) Any other coronary artery disease/procedure (i) Cardiac arrhythmia If 'Yes', when was the last recorded occurrence? DDDDMMMMYYYYYYYY AND complete question 2(c) (j) Peripheral arterial disease 2 Cardiac investigations Yes No (a) Has the applicant undergone an exercise ECG test If 'Yes'. please give date and provide full details in section E: DDDDMMMMYYYYYYYY (b) Has the applicant undergone a myocardial perfusion scan or stress echo study If 'Yes'. please give date and provide full details in section E: DDDDMMMMYYYYYYYY (c) Has the applicant had an LVEF reading taken? Please provide the reading (e. g. 40% or 0. 4): Please provide the date reading was taken AND provide full details in section E: DDDDMMMMYYYYYYYY If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. GP's signature Surgery Stamp Date DDDDMMMMYYYYYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 3 June 18Restricted when completed This page must be endorsed with applicant/drive r's name, examining docto r's signature, su rgery stamp and d ate This page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date TM004291 PT3 (Proof 5) Front Black Cyan Magenta Yellow

6 of 123 Other Cardiovascular disease/procedure Does the applicant have a history of: Yes No (a) Aortic aneurysm If 'Yes'. please provide the following: (i) Site of aneurysm Thoracic Abdominal (ii) Has it been successfully repaired? (iii) Please provide size of aortic diameter.............................................. and date obtained: DDDDMMMMYYYYYYYY (b) Dissection of the aorta If 'Yes'. please provide copies of all reports to include those dealing with any surgical treatment (c) Hypertension (d) Systolic reading consistently above 180/diastolic reading consistently above 100 (e) Please provide a current blood pressure reading ............................................................ (f) Cardiomyopathy If 'Yes'. please state which type:............................................................................................ AND provide full details in section E (g) Congenital heart disorders (h) Any other cardiac condition(s) not listed above If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. 4 Musculoskeletal Does the applicant have a history of: Yes No (a) Does the applicant have any deformity or physical disability (with special attention paid to the conditions of the arms, legs, hands and joints) (b) Is this likely to interfere with efficient discharge of his or her duties as a vocational driver If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. GP's signature Surgery Stamp Date DDDDMMMMYYYYYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 3 June 18Restricted when completed 7 of 125Diabetes Mellitus Yes No (a) Does the applicant have diabetes mellitus? If 'No', please continue to question 6 If 'Yes', is it managed by: (i) Diet alone (ii) Oral hypoglycaemic agents not likely to cause hypoglycaemia (including metformin) (iii) Oral hypoglycaemic agents with potential to cause hypoglycaemia including gliptins, sulphonyurea, glinides, exenatide, and/or others If 'Yes' please give date started on agents and complete ALL DDDDMMMMYYYYYYYY of question (b) below (iv) Insulin If 'Yes' please give date started insulin and complete ALL DDDDMMMMYYYYYYYY of question (b) below (b) Diabetic history Yes No (i) During the past 12 months prior to the date of the licence application, has the applicant had a hypoglycaemic episode requiring the assistance of another at any time (If 'Yes' please provide further details in Section E) No Yes (ii) Does the applicant have a history of responsible diabetic control (If 'No' please provide further details in Section E) No Yes (iii) Does the applicant have good hypoglycaemic awareness (If 'No' please provide further details in Section E)) No Yes (iv) As far as you know, is the applicant adherent to treatment protocols, twice daily blood sugars measurements and at times relevant to driving (If 'No' please provide further details in Section E) No Yes (v) Is the applicant at minimal risk (i. e. Low risk) of hypolglycaemic attack resulting in incapacity (If 'No' please provide further details in Section E) Yes No (vi) Does the applicant have any complications of diabetes which may interfere with driving (If 'Yes' please provide further details in Section E) GP's signature Surgery Stamp Date DDDDMMMMYYYYYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004293 TPH/204 Medical Declaration Form Part 3 June 18Restricted when completed This page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date TM004291 PT3 (Proof 5) Reverse Black Cyan Magenta Yellow This pa ge must be endorse d with applicant/driver's name, examining doc tor's si gnature, surge ry sta mp and date

6 of 123Other Cardiovascular disease/procedure Does the applicant have a history of: Yes No (a) Aortic aneurysm If 'Yes'. please provide the following: (i) Site of aneurysm Thoracic Abdominal (ii) Has it been successfully repaired? (iii) Please provide size of aortic diameter.............................................. and date obtained: DDDDMMMMYYYYYYYY (b) Dissection of the aorta If 'Yes'. please provide copies of all reports to include those dealing with any surgical treatment (c) Hypertension (d) Systolic reading consistently above 180/diastolic reading consistently above 100 (e) Please provide a current blood pressure reading ............................................................ (f) Cardiomyopathy If 'Yes'. please state which type:............................................................................................ AND provide full details in section E (g) Congenital heart disorders (h) Any other cardiac condition(s) not listed above If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. 4Musculoskeletal Does the applicant have a history of: Yes No (a) Does the applicant have any deformity or physical disability (with special attention paid to the conditions of the arms, legs, hands and joints) (b) Is this likely to interfere with efficient discharge of his or her duties as a vocational driver If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. GP's signature Surgery Stamp Date DDDDMMMMYYYYYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 3 June 18Restricted when completed 7 of 125 Diabetes Mellitus Yes No (a) Does the applicant have diabetes mellitus? If 'No', please continue to question 6 If 'Yes', is it managed by: (i) Diet alone (ii) Oral hypoglycaemic agents not likely to cause hypoglycaemia (including metformin) (iii) Oral hypoglycaemic agents with potential to cause hypoglycaemia including gliptins, sulphonyurea, glinides, exenatide, and/or others If 'Yes' please give date started on agents and complete ALL DDDDMMMMYYYYYYYY of question (b) below (iv) Insulin If 'Yes' please give date started insulin and complete ALL DDDDMMMMYYYYYYYY of question (b) below (b) Diabetic history Yes No (i) During the past 12 months prior to the date of the licence application, has the applicant had a hypoglycaemic episode requiring the assistance of another at any time (If 'Yes' please provide further details in Section E) No Yes (ii) Does the applicant have a history of responsible diabetic control (If 'No' please provide further details in Section E) No Yes (iii) Does the applicant have good hypoglycaemic awareness (If 'No' please provide further details in Section E)) No Yes (iv) As far as you know, is the applicant adherent to treatment protocols, twice daily blood sugars measurements and at times relevant to driving (If 'No' please provide further details in Section E) No Yes (v) Is the applicant at minimal risk (i. e. Low risk) of hypolglycaemic attack resulting in incapacity (If 'No' please provide further details in Section E) Yes No (vi) Does the applicant have any complications of diabetes which may interfere with driving (If 'Yes' please provide further details in Section E) GP's signature Surgery Stamp Date DDDDMMMMYYYYYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004293 TPH/204 Medical Declaration Form Part 3 June 18Restricted when completed This page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date TM004291 PT3 (Proof 5) Reverse Black Cyan Magenta Yellow This pa ge must be endorse d with applicant/driver's name, examining doc tor's si gnature, surge ry sta mp and date

8 of 126 Neurological Does the applicant have a history of: Yes No (a) Seizure/Epileptic attack and/or having taken anti-convulsant/epileptic medication in the last 10 years (b) A first unprovoked epileptic seizure/solitary fit within the last 5 years (c) Blackout/Impairment of Consciousness (d) Stroke/TIA If 'Yes', please give the date and complete ALL the questions below: DDDDMMMMYYYYYYYY (i) Has there been a full recovery? (ii) Is there any debarring residual impairment that would affect safe driving? (iii) Any other significant risk factors? (iv) Is there any imaging evidence of less than 50% carotid atery stenois? (v) Has exercise/functional testing been undertaken? If 'Yes', please ensure you complete question 3 of this form (on page 4) (e) Sudden Disabling Dizziness/Vertigo (f) Pathological Sleep Disorder (g) Chronic and/or Progressive Neurological Disorder (h) Brain Surgery (i) Traumatic Brain Injury (j) Brain Tumour If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. GP's signature Surgery Stamp Date DDDDMMMMYYYYYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 3 June 18Restricted when completed 5 of 121Cardiovascular disease/procedure Does the applicant have a history of: Yes No (a) Acute Coronary Syndrome including Myocardial infarction If 'Yes', please provide date(s): DDDDMMMMYYYYYYYY (b) Coronary artery by-pass graft (CABG) If 'Yes', please provide date(s): DDDDMMMMYYYYYYYY (c) Percutaneous Coronary Intervention (P. C. I,) (Angioplasty) If 'Yes', please give date of most recent intervention: DDDDMMMMYYYYYYYY (d) Angina If 'Yes', please give date of the last know attack: DDDDMMMMYYYYYYYY (e) Heart failure (f) Implantable Cardioverter Defibrillator (ICD) (g) Cardiac Pacemaker (h) Any other coronary artery disease/procedure (i) Cardiac arrhythmia If 'Yes', when was the last recorded occurrence? DDDDMMMMYYYYYYYY AND complete question 2(c) (j) Peripheral arterial disease 2Cardiac investigations Yes No (a) Has the applicant undergone an exercise ECG test If 'Yes'. please give date and provide full details in section E: DDDDMMMMYYYYYYYY (b) Has the applicant undergone a myocardial perfusion scan or stress echo study If 'Yes'. please give date and provide full details in section E: DDDDMMMMYYYYYYYY (c) Has the applicant had an LVEF reading taken? Please provide the reading (e. g. 40% or 0. 4): Please provide the date reading was taken AND provide full details in section E: DDDDMMMMYYYYYYYY If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. GP's signature Surgery Stamp Date DDDDMMMMYYYYYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 3 June 18Restricted when completed This page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date TM004291 PT3 (Proof 5) Front Black Cyan Magenta Yellow This page m ust be endorse d with applicant/driver's name, examining doc tor's si gnature, surge ry sta mp and date

4 of 12Tf L recommends that all individuals take a photocopy of this form once it is completed for their own record before submitting the original. D-Medical Conditions-to be completed by Medical Practitioner Sections D-F must be completed by a Medical Practitioner who should:-Have access to the individual's full medical records.-Conduct a physical examination in person when completing this form.-Each page must be endorsed with applicant/driver's name, examining doctor's signature, surgery stamp and date.-Answer all the relevant questions and provide copies of any reports.-Consult the DVLA's publication 'Assessing fitness to drive: A guide for medical professionals' https://www. gov. uk/guidance/assessing-fitness-to-drive-a-guide-for-medical-professionals Regulations state that taxi and PHV drivers must satisfy Tf L that they are medically fit to hold a driver's licence. In assessing whether an applicant is medically fit, Tf L will have regard to the medical standard that would apply in relation to a DVLA Group 2 licence. If you answer 'Yes' to ANY of the questions on this medical form, you must consult the DVLA's publication 'Assessing fitness to drive: a guide for medical professionals' and provide ALL the relevant information required for the condition(s) in accordance with the requirements of a Group 2 licence entitlement. TM004291 TPH/204 Medical Declaration Form Part 2 June 18Restricted when completed 9 of 127 Vision Important information for doctors Please read the information below. In order to complete the following questions you may wish to refer the applicant to an optician or optometrist to ensure all questions can be answered accurately. Requirements Q a visual acuity of at least 6/7. 5 (decimal Snellen equivalent 0. 8) in the better eye Q a visual acuity of at least 6/60 (decimal Snellen equivalent 0. 1) in the other eye Q this may be achieved with or without glasses or contact lenses Q 3 metre readings must be converted to the 6 metre equivalent Q If glasses are worn (not contact lenses) to meet the minimum standards, they should have a corrective power of < + 8 dioptres. Q Complete loss of vision in one eye is a bar to licensing Uncorrected Visual Acuity Corrected Visual Acuity Prescription Left 6/ 6/ Right 6/ 6/ Yes No (a) Does the applicant use corrective lens? If Yes, glasses contact Lenses both together No Yes (b) Does the applicant have a normal binocular field of vision? Yes No (c) Does the applicant have uncontrolled diplopia? Yes No (d) Does the applicant have any other ophthalmic condition? Date DD M MYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291TPH/204 Medical Declaration Form Part 2 June 18Restricted when completed- Write inside the boxes-use BLOCK CAPITAL letters and black ink.-If you make a mistake, please cross it out (initial it) and write the correct information underneath.-Do not use correction fluid-Ensure that a response is provided for every question, unless specifically directed to the contrary. GP s/Optician s signature' ' GP s/Optician s stamp' ' TM004291 PT2 (Proof 5) Reverse Black Cyan Magenta Yellow This page must be endorsed with applicant/drive r's name, examining doctor/optici an's signature, su rgery/optician s tamp and date

10 of 128 Psychiatric Does the applicant have a history of: Yes No (a) Psychiatric Disorder (b) Psychotic Illness (c) Dementia/Cognitive Impairment (d) Alcohol Misuse (e) Alcohol Dependency (f) Drug or Substance Misuse (g) Drug or Substance Dependency 9 Any other conditions Yes No (a) Does the applicant named in section A suffer from any recognised medical condition (such as severe asthma, allergic reaction or chronic phobia) that would preclude them from carrying Guide and/or Assistance dogs? If YES, please request form TPH/208, which must be completed by a Specialist in the field that you require exemption. Yes No (b) (i) Does the applicant suffer from any other disease or disability that has not been previously mentioned? Yes No (ii) Is this likely to interfere with the efficient discharge of his or her duties as a vocational driver, or to cause driving by him or her to be a source of danger to the public? If you answer 'Yes' to any of the above, please provide further details in section E and submit any relevant reports. GP's signature Surgery Stamp Date DD M MYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 2 June18Restricted when completed 3 of 12C-Applicant/Driver Consent and Declaration Privacy Notice Transport for London (Tf L) its subsidiaries and service providers will use your personal information (including any references to your health, ethnic origin, nationality, or previous criminal convictions), for the purpose of assessing your application, administering the licensing regime and equal opportunities monitoring. We will also provide you with information relating to the licensing and regulation of taxi and private hire services in London. Your personal information will be properly safeguarded and processed in accordance with the requirements of privacy and data protection legislation. Your name, badge/licence number and the status, start/expiry date of your licence may be made available on request or on a register for public inspection. If you have licensed a vehicle; the vehicle registration mark, licence number and expiry date may also be made available in the same way. We may share your information with, or receive information from, the Driver and Vehicle Licensing Agency (DVLA), Home Office Immigration Enforcement, Department for Work and Pensions (DWP), Motor Insurer's Bureau (MIB), Driver and Vehicle Standards Agency (DVSA), local authorities and other relevant organisations, including private hire operators, for the purposes of assessing your application or continuing fitness to hold a licence. In certain circumstances, Tf L may also share your personal information with the police and other agencies for the purposes of the prevention and detection of crime. For more information see www. tfl. gov. uk/privacy Consent and Declaration I hereby consent to Transport for London (Tf L) and their medical advisers processing personal data relating to my medical conditions for the purpose of assessing my fitness to hold a taxi or PHV Driver licence. I also give consent for my doctors and specialists to provide Tf L with any data they require in relation to this application. Signature Date DD M MYYYY TM004291 TPH/204 Medical Declaration Form Part 2 June 18Restricted when completed I declare that all information provided on this medical form is true and correct to the best of my knowledge. I understand that the issue of a licence in respect of this medical can be refused and any licence can be revoked if any statements aresubsequently found to be false. I undertake to keep Tf L informed of any changes to any details supplied in this form, and I am aware that failure to do so will constitute a breach of my licence condition and may lead to the possible revocation and suspension of my licence.-TM004291 PT2 (Proof 5) Front Black Cyan Magenta Yellow This pa ge must be endorse d with applicant/driver's name, examining doc tor's si gnature, surge ry sta mp and date

2 of 12A-Personal Details B-Registered NHS GP Details A1 Surname A2 Forename(s) A3 Date of Birth DD M MYYYY A4 Current Address Postcode Rest of address B1 Name of Registered NHS GP B2 Address Postcode Premises number Rest of address TM004291 TPH/204 Medical Declaration Form Part 1 June 18This page is to be fully completed by Applicant/Driver 11 of 12E-Further Details Please use the space below to provide further, legible details required with reference to any of the previously answered questions. Please include relevant dates. It will be necessary to consult the DVLA's publication 'Assessing fitness to drive: a guide for medical professionals' and provide information as per Group 2 standards of fitness. https://www. gov. uk/guidance/assessing-fitness-to-drive-a-guide-for-medical-professionals Please continue on a separate sheet If required. Any additional sheets must be endorsed with the medical practitioner's signature, stamp and date. GP's signature Surgery Stamp Date DD M MYYYY Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 1 June 18Restricted when completed Restricted when completed TM004291 PT1 (Proof 5) Reverse Black Cyan Magenta Yellow This page m ust be endorse d with applicant/driver's name, examining doc tor's si gnature, surge ry sta mp and date

12 of 12F-Declaration-to be completed by Medical Practitioner carrying out the examination Please ensure all sections of the form have been completed. Failure to do so will result in the form being invalid. At the time of the physical examination and completion of this medical form, I had possession of the individual's full medical records. Yes No Where 'No', please state your reason(s) why: Examining doctor's details To be completed by the doctor. Please print name and address in capital letters Practice Name Address Phone I confirm that this report was completed by me at the physical examination and that I am currently GMC registered and licensed to practice in the UK. GP's signature Surgery Stamp GMC Registration number Date DD M MYYYY Name (BLOCK CAPITALS) Applicant/Driver's name (BLOCK CAPITALS) TM004291 TPH/204 Medical Declaration Form Part 1 June 18Restricted when completed TPH/204 V7. 0, 04/06/2018 1 of 12Transport for London London Taxi and Private Hire TPH/204 Medical Declaration TM004291 TPH/204 Medical Declaration Form Part 1 June 18 MAYOR OF LONDONTransport for London (Tf L), the Licensing Authority, needs to be satisfied that all licensed London taxi and Private Hire vehicle drivers are medically fit. In assessing an individual's medical fitness, Tf L has decided to be guided by the DVLA Group 2 standards. This form should be taken to a registered medical practitioner who has access toyour full medical records, typically your GP, for completion. If it is not completed by processing of your application. It is your responsibility to ensure that all your This medical report is for the confidential use of Tf L. This medical report cannot be issued free of charge as part of the National Health Service. The applicant must pay the medical practitioner's fee, unless other arrangements have been made. If you possess a valid DVLA Group 2 licence or are already licensed by Tf L as either a taxi or PHVdriver and are now applying for the other licence, you do not need to have this form completed,unless this form has been requested to confirm your age related fitness. You are required to declareall medical conditions to the registered practitioner for the purpose of assessing your fitness to On completion, this form should be returned to: TFL London Taxi & Private Hire PO Box 177 Sheffield S98 1JY Further information may be requested from you should it be required in order to determine your Tf L recommends that all individuals take a photocopy of this form once it is completed for their own record before submitting the original. v7. 0Restricted when completed Yes No Where 'No', please confirm how you accessed the individual's full medical records:Are you the individual's registered NHS GP? medical conditions (if any) are declared to the medical practitioner completing this form. Please be aware that you will be required to undergo a physical examinationsomeone who has access to your full medical records this could lead to delays in the whilst this form is being completed. Tf L accepts no liability to pay it. hold a taxi or PHV Driver licence. medical fitness. TM004291 PT1 (Proof 5) Front Black Cyan Magenta Yellow This pa ge must be endorse d with applicant/driver's name, examining doc tor's si gnature, surge ry sta mp and date