Figure 1. Mobility Questionnaire

“I want to ask some questions about your driving habits, 
but first, I need to get some general information about you.” 

NOT FOR MARYLAND MVA USE 

First Name, Middle Initial,  Last Name

Gender: (1) Male; (2) Female 

Date of Birth (YYYY, MM, DD)

Race:(1) African-American; (2) American Indian; (3) Asian; (4) Caucasian; (5) HispaniC; (6) Other 

Driver’s License Number: 

Employment Status: (1) Unemployed; (2) Working Part Time; (3) Working Full Time; (4) Retired 

“Now, I have some questions about how much you drive.” 

1.How many days per week do you normally drive? 

2.How many total miles do you drive in a normal week? 

3.About how many miles per year do you drive? 

• less than 1,000
• 1,001 to 2,500
• 2,501 to 5,000
• 5,001 to 7,500
• 7,501 to 10,000 
• 10,001 to 12,500 
• 12,501 to 15,000
• 15,001 to 17,500
• 17,501 to 20,000 
• 20,001 to 25,000
• 25,001 to 30,000
• 30,001 or more

“These next questions are about when and where you drive. Answer these questions based upon your driving habits within the last 3 months. I want you to respond to each question with one of these answers: ‘Always, Usually, Sometimes, Rarely, Never.’” 

(Present the driver with the card that lists the response choices. For each statement, circle the number below the chosen frequency estimate.) 

4a. Do you avoid driving at night? 

4b. Do you avoid making left turns across oncoming traffic? 

4c. Do you avoid driving in bad weather (rain, snow, fog, etc.?) 

4d. Do you avoid driving on high-traffic roads? 

4e. Do you avoid driving in unfamiliar areas? 

4f. Do you pass up opportunities to go shopping, visit friends, etc., because of concerns about driving? 

“The last set of questions addresses various health issues, plus habits and preferences that may have a bearing on how well your transportation needs are met.” 

5. Have you fallen to the floor or ground in the past 3 years? (NOTE: A trip or stumble doesn’t count) 

6. Would you have difficulty walking one block or climbing one flight of stairs?