Manitoba
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Manitoba Seniors and Healthy Aging Secretariat

Seniors & Healthy Aging Secretariat
Winnipeg MB R3C 3H8
Phone: 945-6565
Toll free: 1-800-665-6565
Email: seniors@gov.mb.ca



The Older and
Wiser Driver


Self Rating Form

Instructions:
For each of the following 15 questions check the symbol
(Red Square Yellow Triangle Green Circle ) of the one answer that applies to you. 		Always or almost always Some-Times Never or Almost Never
1. I signal and check to the rear when I change lanes. Green Circle Red Square Red Square
2. I wear a seat belt. Green Circle Red Square Red Square
3. I try to stay informed on changes in driving and highway regulations. Green Circle Yellow Triangle Red Square
4. Intersections bother me because there is so much to watch from all directions. Red Square Yellow Triangle Green Circle
5. I find it difficult to decide when to join traffic on a busy highway. Red Square Yellow Triangle Green Circle
6. I think I am slower than I used to be in reacting to dangerous driving situations. Red Square Red Square Green Circle
7. When I am really upset, I show it in my driving. Red Square Red Square Green Circle
8. My thoughts wander when I am driving. Red Square Yellow Triangle Green Circle
9. Traffic situations make me angry. Red Square Yellow Triangle Green Circle
10. I get regular eye checks to keep my vision at its sharpest. Green Circle Red Square Red Square
11. I check with my doctor or pharmacist about the effect of my medications on driving ability. (If you do not take any medication, skip this question) Green Circle Red Square Red Square
12. I try to stay abreast of current information on health practices and habits. Green Circle Yellow Triangle Red Square
13. My children, other family members or friends are concerned about my driving ability. Red Square Yellow Triangle Green Circle
  None One or Two Three or More
14. How many traffic tickets, warnings, or "discussions" with officers have you had in the past two years? Green Circle Yellow Triangle Red Square
15. How many accidents have you had during the past two years? Green Circle Red Square Red Square