CDME Module 2: Vision, Hearing, Diabetes Mellitus-Insulin-Treated Diabetes Mellitus Assessment Form (MCSA 5870)

Insulin-Treated Diabetes Mellitus Assessment Form (MCSA 5870)

Pdf Summary

The document is titled "INSULIN-TREATED DIABETES MELLITUS ASSESSMENT FORM" and is intended for individuals who are being evaluated for their ability to operate a commercial motor vehicle or have recently experienced a severe hypoglycemic episode. The form is to be completed by a treating clinician who manages and prescribes insulin for the individual's diabetes. <br /><br />The form includes sections for the individual to provide information on their insulin use, blood glucose self-monitoring records, severe hypoglycemic episodes, HbA1C measurements, diabetes complications, progressive eye diseases, and additional comments. It is important for individuals to maintain at least three months of electronic blood glucose self-monitoring records while being treated with insulin in order to qualify to operate a commercial motor vehicle. The form also asks about the individual's compliance with blood glucose self-monitoring based on their specific treatment plan.<br /><br />The form includes sections for the treating clinician to provide additional details and comments on the individual's medical history, including diagnoses, treatments, and stability of conditions such as renal disease, cardiovascular disease, neurological disease, peripheral neuropathy, lower limb conditions, progressive eye diseases, and other conditions.<br /><br />The treating clinician is required to sign and attest to the accuracy of the information provided. The document also includes a warning about the sensitivity of the information and the need to handle and secure it appropriately to prevent unauthorized disclosure.

Keywords

Insulin-treated diabetes mellitus

Assessment form

Commercial motor vehicle

Severe hypoglycemic episode

Treating clinician

Insulin use

Blood glucose self-monitoring

HbA1C measurements

Diabetes complications

Progressive eye diseases