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Multiple Sclerosis
Services
Outpatient Medical
Rehabilitation
Adult
Brain Injury
Concussion Care
Limb Loss
Pediatric & Adolescent
Summer Programming
Senior
Specialized Expertise
Spina Bifida
Spinal Cord Injury
Stroke
Vision
Therapeutic
Preschool
ABA
Outpatient Therapy
Therapeutic Preschool
Employment
Services
Ability KC Industries
Employment Services
Summer Work Experience
Speciality
Services
Assistive Technology
Aquatic Therapy
Driving Program
EXCEL Program
Neuropsychology
Rehabilitation
Technology
Admissions
Getting Started
Bill Pay
Insurance
Resources
Resource Library
FAQ
News
Blog
Events
Stroke Conference
Wheelchair Wash
Ability Luncheon
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Driving Pre-Admit Info
Step
1
of
7
14%
Name
*
Required
First
Last
Date of Birth
- must be mm/dd/yyyy format
*
Required
MM slash DD slash YYYY
Age
*
Required
Address
*
Required
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
County of Residence
*
Required
Cell Phone
*
Required
Home Phone
Email
*
Required
Social Security #
*
Required
Sex
*
Required
Male
Female
Other
Race
*
Required
African American
American Indian or Alaska Native
Asian
Hispanic or Latino
Native Hawaiian or Pacific Islander
White
Other
Marital Status
*
Required
Married
Widowed
Separated
Divorced
Single
Medical Diagnosis
Onset Date
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Emergency or Other Contact Information
Name
*
Required
First
Last
Phone
*
Required
Address
*
Required
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Relationship
*
Required
Name
First
Last
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Relationship
Legal Guardian/Power of Attorney (if any)
First
Last
Phone
Address
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Relationship
Physician Information
Referring Physician Name
*
Required
First
Last
Address
*
Required
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Required
Primary Care Physician Name
*
Required
First
Last
Address
*
Required
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Phone
*
Required
Payment Information
Who is paying for this evaluation?
*
Required
Yourself
Vocational Counselor
Workers Compensation
If you selected vocational counselor please provide their name.
First
Last
If you selected workers compensations please provide the case manager's name.
First
Last
If you selected vocational counselor or workers compensation please list their phone number.
Why are you being referred for a driver's evaluation?
*
Required
Health Questions
Medical History: Please select if you have or have had any of the following.
*
Required
ADHD
Arthritis
Cancer
Cardiac Issues
Changes In Memory
Diabetes
Dizziness
Glaucoma
Hearing Impairment
Learning Issues
Macular Degeneration
Mood Disorders
Other Vision Problems
Sensory Changes In Feet
Stroke
Substance Abuse
Vertigo
Please explain all selected items, including procedures, dates, and whether or not you are under the care of a physician for that condition.
*
Required
Have you ever been hospitalized?
Yes
No
If yes, how many times, when and what were you hospitalized for?
List all medications you are taking and why.
Please check all that describe yourself.
*
Required
Memory Problems
Peripheral Vision Deficits
Double Vision
Blurry Vision
Difficulty Speaking
Difficulty Understanding Others
Difficulty Reading
Hearing Impairment
Left Arm Weakness/Paralysis
Right Arm Weakness/Paralysis
Left Leg Weakness/Paralysis
Right Leg Weakness/Paralysis
I can walk.
I use a cane
I use a walker.
I need assistance for self care.
I manage my own medication.
Height
*
Required
Weight
*
Required
Hand Dominance
*
Required
Left Hand
Right Hand
Have you had a seizure in last six months?
*
Required
Yes
No
If "yes" please indicate the date of your last seizure.
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Please list any other disability you may have that could have an effect on your driving ability.
Do you have any problems with your vision, and/or have you ever had therapy to improve your visual scanning/functioning abilities?
*
Required
Yes
No
Briefly describe/list any pertinent medical history not addressed above:
Date of last eye examination:
- must be mm/dd/yyyy format
*
Required
MM slash DD slash YYYY
Have you ever received services at Ability KC?
*
Required
Yes
No
What kind of service did you receive and when?
If You Are A Wheelchair User Please Complete The Following Section
What type of wheelchair do you use?
NA
Manual
Power
Power Assist
Wheelchair Make
Wheelchair Model
Can you transfer independently from your wheelchair to and from a vehicle?
NA
Yes
No
Can you independently load and unload your wheelchair in and out of a vehicle?
NA
Yes
No
Driving History
When was the last time you drove?
- must be mm/dd/yyyy format
MM slash DD slash YYYY
Where did you drive?
Driver's License Number or Permit Number
Expiration Date
- must be mm/dd/yyyy format
MM slash DD slash YYYY
During your last 5 years of driving, have you has any tickets or accidents (an accident is anytime you hit an object or have been hit by someone else, even if you did not receive a ticket)?
*
Required
Yes
No
If "yes", please explain.
Have you ever had your license revoked, suspended, or voluntarily surrendered?
*
Required
Yes
No
If "yes", please explain.
Have you ever had a DUI?
*
Required
Yes
No
If so, when?
- must be mm/dd/yyyy format
MM slash DD slash YYYY
What year vehicle will you primarily be driving?
*
Required
What make vehicle will you primarily be driving?
*
Required
What model vehicle will you primarily be driving?
*
Required
What type of transmission does your primary vehicle have?
Automatic
Manual
What type of driving do you expect to do after completing this evaluation/training? Please select all that apply.
Commercial
Interstate
Long Trips
Night
Residential
Rush Hour
Where will you do the most of your driving?
*
Required
Do you currently, or have you thought about, limiting your driving in anyway?
*
Required
Yes
No
Please explain.
The preceding information is true to the best of my knowledge. I understand that falsification of any of the above information would prohibit my participation in the driving program. I understand that non-disclosure of medical or mental health information may affect the validity of the results of my evaluation
*
Required
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Multiple Sclerosis
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Services
Outpatient Medical
Rehabilitation
Adult
Brain Injury
Concussion Care
Limb Loss
Pediatric & Adolescent
Summer Programming
Back
Senior
Specialized Expertise
Spina Bifida
Spinal Cord Injury
Stroke
Vision
Back
Therapeutic
Preschool
ABA
Outpatient Therapy
Therapeutic Preschool
Back
Employment
Services
Ability KC Industries
Employment Services
Summer Work Experience
Back
Speciality
Services
Assistive Technology
Aquatic Therapy
Driving Program
EXCEL Program
Neuropsychology
Back
Rehabilitation
Technology
Back
Admissions
Getting Started
Bill Pay
Insurance
Back
Resources
Resource Library
FAQ
News
Blog
Back
Events
Stroke Conference
Wheelchair Wash
Ability Luncheon
Annual Groundhog Run
Community Events
All Events
Back
About
History
Mission & Vision
Leadership
Annual Report
Partnerships
Locations
Areas Served
Back
Stories
Contact
Email Us
Volunteer
Internship
Careers
Referrals
Back
