Medical Assessment For Drivers With Insulin-Treated Diabetes - Nova Scotia
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1Service Nova Scotia
1505 Barrington Street
Medical Assessment for
9 North
and Municipal Relations
Halifax, Nova Scotia
Drivers with Diabetes
Motor Vehicle Administration
B3J 3K5
Tel: (902) 424-5732
Fax: (902) 424-0772
Note: To be completed by a qualified medical doctor familiar with your medical history.
Patient Information and Consent
Date of Birth: ______________________________________________
Name: ____________________________________________________
Address: __________________________________________________
Telephone: Home (
) _____________ Work (
) _____________
__________________________________ Postal Code: ____________
Cellular (
) _______________
x y z { | } ~
Master No: ________________________________________________
Class of licence (check one):
I certify that the information I have provided to the physician concerning my diabetes is accurate. I authorize the release of any information concerning
my medical condition to the Motor Vehicle Administration Section.
_____________________________________________________________________________________
___________________________________________________
PATIENT’S/DRIVER’S SIGNATURE
DATE
How long have you treated this patient for a diabetic condition? __________________________
Does patient experience severe hypoglycemic episodes (ie., severe mental confusion, seizures, coma) without warning?
K
Yes
K
No
If “Yes,” please describe fully ______________________________________________________________________________________________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Within the past two years has patient suffered an episode of hypoglycemia?
K
Yes
K
No
loss of consciousness?
K
Yes
K
No
If “Yes,” please indicate the date(s) and type(s) of treatment (eg., self-treated, treated by another person or treated at the hospital) _____________
______________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________
Does patient have knowledge of the causes, symptoms, and treatment of hypoglycemia?
K
Yes
K
No
Does patient have any of the following complications:
K
Neuropathy
K
Retinopathy
K
Peripheral Vascular Disease
K
Nephropathy
K
Angina
Has patient followed your directions for the care of diabetes?
K
Yes
K
No
HgAIC level ________________ Date performed __________
Blood glucose ______________ Date Performed __________
Please give your opinion of the patient’s ability to safely operate the class of motor vehicle as indicated above.
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Physician’s Name: __________________________________ Address: ______________________________________________________________
City/Town: __________________________________ Province: __________________________________ Postal Code: _______________________
Telephone: (
) ________________________ Fax: (
) ________________________
_____________________________________________________________________________________
___________________________________________________
PHYSICIAN’S SIGNATURE
DATE
Rep 47 Rev 12/08
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