Form Dl-122 - Diabetic Form

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DL-122 (4-12)

DIABETIC FORM

Bureau of Driver Licensing

P.O. Box 68682

Harrisburg, PA 17106-8682

PLEASE TYPE OR PRINT ALL INFORMATION IN BLUE OR BLACK INK

(717) 787-9662

THIS FORM APPROVED BY THE MEDICAL ADVISORY BOARD 4/13/12

Provider: For more information relating to Medical Reporting, visit

PATIENT INFORMATION (Please complete this form in its entirety unless otherwise noted)

DRIVER’S LICENSE NO.

LAST NAME(S)

JR. ETC

FIRST NAME

HEIGHT

SEX

EYE COLOR

DATE OF BIRTH

TELEPHONE NUMBER

FEET

INCHES

MONTH

DAY

YEAR

STREET ADDRESS: P.O. Box number may be used in addition to the actual address, but cannot be used as the only address.

STATE

CITY

ZIP CODE

1. How long have you been treating the patient? ______________________________________________________________

2. Do you treat the patient on a regular basis? _______________________________________________________________

3. Has the patient been diagnosed with diabetes mellitus? ______________________________________________________

PLEASE NOTE: IF PATIENT HAS BEEN DIAGNOSED WITH DIABETES, PAGE 2 OF THIS FORM MUST BE COMPLETED.

4. Has the patient been diagnosed with unstable diabetes mellitus? ______________________________________________

If yes, please continue. If no, you may move on to complete page 2.

a. Within the past 6 months, has it led to severe hypoglycemic reaction(s) that required outside intervention or assistance

of others or that produced confusion, loss of attention or a loss of consciousness? ______________________________

If yes, date of episode(s): ___________________________________________________________________________

b. Within the past 6 months, has it led to symptomatic hyperglycemia, which caused a loss of consciousness or an altered

state of perception, including, but not limited to, decreased reaction time, impaired vision or hearing, or both, and

confusion? ____________ If yes, date of episode(s): _____________________________________________________

c. If yes, did the episode(s) occur while under a health care provider's supervision? _______________________________

d. If yes, did the episode(s) occur during or concurrent with a nonrecurring transient illness, toxic ingestion or

metabolic imbalance? _____________________________________________________________________________

e. If yes, was the episode(s) caused by a temporary condition or isolated incident that is not likely to recur? ____________

5. Is the patient being treated with medication? ______________________________________________________________

If yes, type:______________________________________________ dosage: ____________________________________

6. What were the results of the patient's most recent HbA1C screening? _____________________ date of test : ___________

HEALTH CARE PROVIDER INFORMATION (Please print or type)

HEALTH CARE PROVIDER'S NAME

SPECIALTY

HEALTH CARE PROVIDER'S LICENSE NUMBER

STREET ADDRESS

CITY

STATE

ZIP CODE

TELEPHONE NUMBER

FAX NUMBER

I hereby state that the facts above set forth are true and correct to the best of my knowledge, information and belief. I understand that the statements made herein

are made subject to the penalties of 18 Pa. C. S. §4904 (relating to unsworn falsification to authorities). Punishable by a fine up to $2,500 and/or imprisonment

up to 1 year.

Health Care Provider's Signature

Date

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