CDME Module 2: Vision, Hearing, Diabetes Mellitus-2-4: Insulin Treated Diabetes Mellitus Assessment Form

2-4: Insulin Treated Diabetes Mellitus Assessment Form

Pdf Summary

The document contains a form titled "Insulin-Treated Diabetes Mellitus Assessment Form" used by the Federal Motor Carrier Safety Administration (FMCSA) to evaluate individuals with insulin-treated diabetes. The form requires information such as the date insulin use began, blood glucose self-monitoring records, history of severe hypoglycemic episodes, HbA1C measurements, and signs of diabetic complications or target organ damage. The form is to be completed by a treating clinician and does not imply a medical certification decision for the individual to drive a commercial motor vehicle. The individual must provide at least 3 months of electronic blood glucose self-monitoring records to qualify for operating a commercial motor vehicle for up to 12 months. Various questions are posed in the form regarding the individual's blood glucose testing frequency, compliance with self-monitoring, history of severe hypoglycemic episodes, HbA1C measurements, and diabetic complications. The form also includes questions about progressive eye diseases and additional comments. The treating clinician must sign the form, confirming their status and attesting to the accuracy of the provided information. Once completed, the form is to be given to a certified medical examiner for further evaluation.

Keywords

Insulin-Treated Diabetes Mellitus Assessment Form

Federal Motor Carrier Safety Administration

insulin-treated diabetes

blood glucose self-monitoring records

severe hypoglycemic episodes

HbA1C measurements

diabetic complications

target organ damage

commercial motor vehicle

treating clinician