Appendix 10

Sample Diabetes and Driving Assessment Form

Sample Diabetes and Driving Assessment Form
Type of diabetes:
▢ type 1 ▢ type 2 ▢ other
Type of diabetes:
___________________________________
For private drivers with diabetes, in the past 6 months, have there been any episodes of severe hypoglycemia
▢ while awake?
  Specify number and date(s)___________________________
▢ while driving?
  Specify number and date(s)___________________________
▢ while asleep?
  Specify number and date(s)___________________________
Has the driver had evidence of hypoglycemia unawareness in the past 6 months?
▢ Yes ▢ No
If yes, has there been recovery of hypoglycemia awareness?
▢ Yes ▢ No
Diabetes treatment
▢ nutritional therapy/healthy beahviour interventions alone
▢ insulin
▢ sulfonylurea/meglinitide
▢ other noninsulin antihyperglycemic agent (metformin, alpha-glucosidase inhibitor, glitazone [TXD], GLP-1 receptor agonist, DPP-4 inhibitor or SGLT2 inhibitor)
Most recent A1C (within last 6 months)
▢ ≤7.0%
▢ 7.1-8%
▢ 8.1-11.9%
▢ ≥12%
For commercial drivers with diabetes, in the past 12 months, have there been any episodes of severe hypoglycemia
▢ while awake?
  Specify number and date(s)___________________________
▢ while driving?
  Specify number and date(s)___________________________
▢ while asleep?
  Specify number and date(s)___________________________
Has the driver had evidence of hypoglycemia unawareness in the past 6 months?
▢ Yes ▢ No
If yes, has there been recovery of hypoglycemia awareness?
▢ Yes ▢ No
Blood glucose monitoring
Is the driver with diabetes maintaining a log of their self-monitored blood glucose measurements with either a memory-equipped blodd glucose meter or electronic record?
▢ Yes ▢ No
Are A1C results consistent with blood glucose logs?
▢ Yes ▢ No
For drivers on insulin or insulin secretagogues, is there evidence of blood glucose monitoring at least every 4 hours while driving or wearing of continuous blood glucose monitoring device?
▢ Yes ▢ No
Hypoglycemia
Does the driver with diabetes have awareness of early symptoms of hypoglycemia (e.g. palpitations, shakiness, anxiety, sweating, hunger, tingling)?
▢ Yes ▢ No
Does the driver iwth diabetes know how to treat hypoglycemia?
▢ Yes ▢ No
For drivers with diabetes treated with insulin or insulin secretagogues, is blood glucose monitoring equipment and supplies of rapidly absorbable carbohydrate within easy reach in the vehicle?
▢ Yes ▢ No
General Health
Does the patient have any of the following complications to an extent that could impair his/her ability to drive safely
▢ Retinopathy ▢ Neuropathy
▢ Chronic Kidney Disease ▢ Amputation
▢ Cardiovascular Disease ▢ Other

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