5Your health
You must fill in either part A or part B or we will send your application back to you.
If you have already told us about a medical condition that could affect your fitness to drive – and you have no new medical condition
– miss out part Aand go on to part B of this section.
Part A
| Have you ever had, or do you currently suffer from | 
| any of the following conditions? | No ■ Yes ■ | 
If you have answered ‘Yes’, please tick all the appropriate boxes.
| 1 | Epilepsy | ■ | 
| 2 | Fits or blackouts | ■ | 
| 3 | Repeated attacks of sudden disabling giddiness | ■ | 
| 4 | Diabetes controlled by insulin | ■ | 
| 5 | Diabetes controlled by tablets | ■ | 
| 6 | An implanted cardiac pacemaker | ■ | 
| 7 | An implanted cardiac defibrillator (ICD) | ■ | 
| 8 | Angina (heart pain) which is easily brought on by driving | ■ | 
| 9 | Persistent alcohol misuse or dependency | ■ | 
| 10 | Persistent drug misuse or dependency | ■ | 
| 11 | Parkinson’s disease | ■ | 
| 12 | Narcolepsy or sleep apnoea syndrome | ■ | 
| 13 | Stroke, with any symptoms lasting longer than | ■ | 
|   | one month, recurrent “mini-strokes” or TIAs | 
| 14 | Any type of brain surgery, severe head injury | ■ | 
|   | involving inpatient treatment, or brain tumour | 
| 15 | Any other chronic neurological condition | ■ | 
| 16 | Aserious problem with memory or periods of confusion | ■ | 
| 17 | Severe learning disability | ■ | 
| 18 | Serious psychiatric illness or mental ill health | ■ | 
| 19 | Total loss of sight in one eye | ■ | 
| 20 | Any condition affecting both eyes, or the remaining eye |   | 
|   | if you only have one eye | ■ | 
|   | (not including colour blindness or short or long sight) | 
| 21 | Any condition affecting your visual field | ■ | 
| 22 | Any persisting limb problem which needs |   | 
|   | driving to be restricted to certain types | ■ | 
|   | of vehicle or those with adapted controls | 
If you have answered YES to one of the above questions you may be required to complete a medical questionnaire. Questionnaires are available on the DVLAwebsite http://www.dvla.gov.uk to be sent in with your application.
Part B
Only fill in this part if you have told us about a medical condition before.
 
You must read pages 6 to 10 of the INF1D before filling in section 6 and 7. Do not fill in sections 6 and 7 or supply a new photograph if you have a photocard licence, unless you are registering a change of name, photograph or signature. UK birth/adoption certificates are not acceptable as sole proof of identity and we may ask for further evidence. We are unable to verify details on non-UK birth certificates and they cannot be accepted as proof of identity.
6Confirming your identity
Tick the documents you are providing to prove your identity – see pages 6, 7 and 8 of INF1D for more details. Photocopies are not acceptable.
Passport ■Your UK birth or adoption certificate ■
EC or EEAidentity card ■ TravelDocument■
Evidence of SRP(State Retirement Pension) ■
Also, please write the identity number of the document you are providing.
Tick the documents you are also providing to show a clear link to your current name if different from that shown on your passport, birth certificate or adoption certificate.
Marriage certificate ■ Divorce certificate ■
Your deed poll or statutory declaration ■
Also,pleasewritetheidentitynumbersofthedocumentsyouareproviding.
7Signing your photograph
Ifyouareprovidingidentitydocumentsotherthananup-to-dateUK,ECor EEApassport,someonereliablemustsignthebackofyourphotograph. (See page 8 and 9 of INF1D for more details.)
Warning: This person must have known you personally for at least two years, and must not be a relative or a member of the Post Office™ staff processing the application, if you choose to use the Premium Checking Service – see page 13 of INF1D for more details.
TO BE FILLED IN BY THE PERSON SIGNING YOUR PHOTOGRAPH.
State how many years you have known the applicant: This MUST be at least 2 years.
I have signed the back of the photograph which is a true likeness of the applicant.
Full name
Business or home address
Postcode
Full daytime phone number
ProfessionQualifications
Warning: We will make random checks on those who sign photographs for driving licence applications.