Drink Drugs Driving Impairment Assessment Form

ASSOCIATION OF FORENSIC PHYSICIANS SECTION 4 RTA ASSESSMENT FORM (Version 6 1 1/04)

1 INTRODUCTION AND GENERAL GUIDANCE

Note: This form has been designed by Dr Ian F Wall on behalf of the Education and Research Committee of the Association of Police Surgeons for use by Police Surgeons (also known as Forensic Medical Examiners or Forensic Physicians) who have been trained in the use of Standardised Impairment Tests, The form is provided to assist Police Surgeons in determining whether a person has a condition, which may be due to drink or drugs and not necessarily due to impairment, It is to be regarded as an aide-memoire and it is therefore not necessary for all parts of the form to be completed. Some details are included so as to aid possible subsequent assessment of fitness for detention in custody. Where a test is abandoned the reasons should be recorded in Additional Particulars at 12, If the questions are read from a card, the wording should be identical to those used in this form and the card must remain available for production at court. On completion this form is the personal property of the examining doctor.

Whilst this form is designed to provide for the recording of findings following the examination of a subject to determine both the persons general medical condition and the degree of any impairment present, it is important to stress that the primary question police require to be answered is Has the person a condition which might be due to some drug? It is not necessary to determine impairment or unfitness to drive,_

GENERAL DETAIL?

Name:

Police station:

Address:

Custody record No:

Date of birth:

Occupation:

Arrest date:

Arrest time:

PNC warnings:

Time Called:

Time Arrived:

Time examination started:

Time examination completed:

BACKGROUND INFORMATION

Road side breath test:

Intoximeter readings:

Information from arresting officer (PC.,

Field impairment test results..

Information from Custody Officer

* Delete as Applicable Page 1

ASSOCIATION OF FORENSIC PHYSICIANS SECTION 4 RTA ASSESSMENT FORM (Version 6.1 1/04)

HEARING PROBLEMS VISUAL PROBLEMS

DIABETES

RENAL

IMPAIRMENT

BALANCE PROBLEMS

ASTHMA

EPILEPSY HEPATIC IMPAIRMENT

Alcohol intake and times in last 24 hours:.

WEEKLY ALCOHOL INTAKE

Units per week

TIME LAST ATE

TIME LAST SLEPT

Past psychiatric history:.

Previous self harm attempts:

Social history:

Relevant educational history (to assess if learning disability etc):.

MEDICATION

DOSE

DURATION

ROUTE

LAST TAKEN

Prescribed

OTC medicines

Non-prescribed

* Delete as Applicable

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* Delete as Applicable

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^^ ASSOCIATION OF FORENSIC PHYSICIANS SECTION 4 RTA ASSESSMENT FORM (Version 6.1 1/04)

EYE EXAMINATION

Use the gauge below or a printed laminated card to assess pupil size:

1.015 ZO 25 3.0 as 4.0 4.5 &o 5.5 ao as 7.0 7.5 ao as ao • • • • • <

EYE EXAMINATION

Use the gauge below or a printed laminated card to assess pupil size:

1.015 ZO 25 3.0 as 4.0 4.5 &o 5.5 ao as 7.0 7.5 ao as ao • • • • • <

EYE SIGNS

RIGHT

LEFT

Conjunctiva

Pupil Size

Direct reflex

Indirect reflex

Visual acuity:

Visual fields:

Horizontal gaze nystagmus

Lack of smooth pursuit

Vertical gaze nystagmus: *YES/NO Spectacles: *YES/NO

Other abnormal eye findings:

Convergence: Contact lens:

IMPAIRMENT TESTS

"I would like you to perform a series of tests to enable me to ascertain whether you have a condition which might be due to drink or drugs, or whether your ability to drive is impaired by drink or drugs. The tests are simple and part of my evaluation will be based on your ability to follow instructions. If you do not understand any of the instructions, please tell me so that I can clarify them. "

* Delete as Applicable

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ASSOCIATION OF FORENSIC PHYSICIANS SECTION 4 RTA ASSESSMENT FORM (Version 6.1 1/04)

3-ROMBERG TEST-

"Stand up straight with your feet together and your arms down by your sides. Maintain that position while I give you the remaining instructions. Do not begin until I tell you to do so. When I tell you to start, you must tilt your head back slightly and close your eyes (demonstrate but do not close your eyes). Keep your head tilted backwards with your eyes closed until you think that 30 seconds have passed, then bring your head forward and say 'Stop'".

"Do you understand? " YES/NO*

ABLE TO STAND STILL DURING INSTRUCTIONS: * YES/NO EXCESSIVE BODY SWAY SEEN: *YES/NO INTERNAL BODY CLOCK: 30SECONDS AT SECS

9 WALK AND TURN TEST

Identify a real or imaginary line.

"Place your left foot on the line. Place your right foot on the line in front of your left touching heel to toe (demonstrate). Put your arms down by your sides and keep them there throughout the entire test. Maintain that position whilst I give you the remaining instructions".

"Do you understand? " YES/NO*

"When I say start, you must take nine heel to toe steps along the line. On each step the heel of the foot must be placed against the toe of the other foot (demonstrate). When the ninth step has been taken, you must leave the front foot on the line and turn around using a series of small steps with the other foot. After turning you must take another nine heel to toe steps along the line. You must watch your feet at all times and count each step out loud. Once you start walking do not stop until you have completed the test".

"Do you understand? " YES/NO*

Dr's name Date * Delete as Applicable Page 6

ABLE TO COMPLETE TEST:

*YES/NO

COMMENTS:

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