2010 BC Guide in Determining Fitness to Drive

11.16 Doctor’s report on commercial driver with diabetes on insulinOffice of the Superintendentof Motor Vehicleswww.pssg.gov.bc.ca/osmvPO BOX 9254 STNPROV GOVTVICTORIA BC V8W 9J2Phone: (250) 387-7747Fax: (250) 952-6888DOCTOR’S REPORT ON COMMERCIAL DRIVER WITH DIABETES ON INSULINNOTE TO THE DOCTOR: on a separate form, the driver has certified that they will: maintain a glycemic log which shows the previous 6 months and records the hours driven and blood glucose checks during that time produce their glycemic log for their doctor’s review when they attend for completion of this form make available records of medical care for the previous 24 months for initial diabetes assessment, and 12 months for re-assessmentPERSONAL HEALTH NUMBER(MUST BE COMPLETED) MSP Fee Code 96222The personal information on this form is collected under the authority of the Motor Vehicle Act, Medicare Protection Act, and the Freedom of Information and Protection of Privacy Act. Theinformation provided will be used to determine your fitness to drive a motor vehicle and allow the physician to bill through the British Columbia Medical Services Plan for the service. Personalinformation is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection of Privacy Act and may be disclosed only as provided by that Act.If you have any questions about the collection, use and disclosure of the information collected, contact the Office of the Superintendent of Motor Vehicles at (250) 387-7747.PART A- GENERAL1. Patient’s name 7. Has there been a significant change in insulintherapy, i.e. introduction of insulin, or a change intype of insulin or number of injections? YES NO2. Age when diagnosed Commercial drivers must present a log of bloodglucose measurements performed at least twice dailyfor the previous six months, or since diagnoses ifdiagnosed in the last 6 months, to their examiningphysician.3. How long have you treated this patient for diabetes? 8a. Does the log indicate adequate self-monitoring ofblood glucose? YES NO4. Result of one HbA1c completed within the last three months.Value:5. Does patient have a full understanding of the diabeticcondition and the relationship between insulin dose, diet andexercise? YES NO6. Has impairment by alcohol ever interfered with patient’sability to maintain good control of their diabetes? YES NO8b. Does the data in this patient’s log indicate stableand effective blood glucose control? YES NO9. Does patient take appropriate action based on bloodglucose results? YES NO10. Is this patient’s work schedule compatible withtheir treatment regime? YES NO108