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

Pdf Summary

This document is a form for assessing individuals with insulin-treated diabetes mellitus. It is used to determine whether an individual is physically qualified to operate a commercial motor vehicle or has recently experienced a severe hypoglycemic episode. The form must be completed by a treating clinician who manages and prescribes insulin for the individual's diabetes mellitus. <br /><br />The form includes sections for documenting the individual's insulin use, blood glucose self-monitoring records, severe hypoglycemic episodes, hemoglobin A1C measurements, diabetes complications, and progressive eye diseases. It also includes sections for providing additional comments and attesting to the accuracy of the information by the treating clinician.<br /><br />The form emphasizes the importance of maintaining proper control of insulin-treated diabetes mellitus and provides instructions to the individual on when to present the form to a certified medical examiner for a medical certification examination.<br /><br />The form includes sections for documenting the individual's compliance with blood glucose self-monitoring, the frequency of blood glucose testing, and any signs of diabetic complications or target organ damage.<br /><br />The form also collects information on the individual's history of severe hypoglycemic episodes, HbA1C measurements, and any progressive eye diseases.<br /><br />The form concludes with the treating clinician's signature and contact information.<br /><br />It is important to note that mishandling this sensitive information could have negative consequences, and the document should be appropriately secured and disposed of when no longer required.

Asset Caption

(MCSA-5870)

Keywords

insulin-treated diabetes mellitus

commercial motor vehicle

severe hypoglycemic episode

treating clinician

insulin use

blood glucose self-monitoring

hemoglobin A1C measurements

diabetes complications

progressive eye diseases

medical certification examination