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DRIVER'S LICENSE NUMBER CASE NUMBER <br /> Yes No <br /> O O B. DiABBES-Initialifmotapplicableandnkip this section. <br /> O O 1. Is patient being treated for diabetes? <br /> If yes, specify insulin dosage and type or oral medication dosage and type. <br /> O O 2. |m there a history of hypoglycemic reactions? <br /> O O |f yes, io there any warning ofreactions? <br /> O [] If no, does the patient check his/her own blood sugar, using a glucose meter, before <br /> driving? <br /> O O 3. If taking insulin, or oral medication, does the patient carry glucose tablets or candy at all <br /> times? <br /> O O 4. |e diabetes under control? <br /> O O C NEUROLOGICAL Initial if not applicable and skip this section. <br /> O O 1. Does your patient have a history of seizures, syncopal attacks, or disabling dizziness? <br /> 2. What in the frequency of these episodes? <br /> When was the last episode? <br /> O O 3, Does your patient presently have any neurological impairment? <br /> |f so, please detail. <br /> O O 4. Do you expect the patient will bu free of seizures in the future? <br /> • O D ORTHOPEDIC'Initial___if not applicable and skip this section. <br /> • O 1. Does the patient have an amputation or skeletal defect that can interfere with driving <br /> ability? If yes, give details. <br /> O O 2. Does the patient use an artificial limb? |f yes, explain. <br /> O O 3. Has the patient any paralysis,joint stiffness, reduced physical dexterity, or limitation of <br /> motion sufficient ho interfere with driving safely? If yes, give details. <br /> O O 4. |n condition stable? <br /> xn&uomort DOT-nz05e(4x09) Page zof4 <br />