The Canadian Diabetes Association has become Diabetes Canada*
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) |
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| 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 |
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| 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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*The Canadian Diabetes Association is the registered owner of the name Diabetes Canada. All content on guidelines.diabetes.ca, CPG Apps and in our online store remains exactly the same. For questions, contact communications@diabetes.ca.