| 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 |