DS-6575 Diabetes

U.S. Department of State

Bureau of Medical Services

OMB APPROVAL NO 1405-XXXX
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: XX MINUTES

DRIVER MEDICAL EXAMINATION: DIABETES MELLITUS*
ASSESSMENT FORM
Instructions: This form is required for all individuals with diabetes who are treated with insulin and must be provided at the time of the initial or periodic
medical evaluation.
*This form is required for insulin-treated diabetes and may be required for individuals with diabetes who are not insulin treated, based on clinical
judgment of the reviewing Driver Medical Evaluation clinician. Failure to provide this form prior to or during the evaluation may result in disqualification
or delays in the evaluation process.
This form should be completed by the medical provider/clinician who manages the driver’s diabetes and who prescribes insulin and/or other medication
for the treatment of diabetes mellitus.

Section I: Driver Information
Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Section II: Diabetes History
Approximate date of diabetes mellitus diagnosis (mm-yyyy)):

MEDICATION
If "Yes", Date Insulin Use Began (mm-dd-yyyy)

Insulin Use?

Yes

If "Yes", Current Insulin Regimen

No or N/A
Name of Medication

Dose

Frequency

Other medications used to
manage diabetes.

BLOOD GLUCOSE
Is the individual compliant
with monitoring based on
his/her specific treatment
plan?
Yes

If "Yes", how many times per day is the individual testing
his/her blood glucose?

If, "Yes", I, the clinician, reviewed the stated individual’s
blood glucose monitoring results from

Date (mm-dd-yyyy)

No

HYPOGLYCEMIC EPISODES
A severe hypoglycemic episode is one that results in symptoms such as loss of consciousness, seizure, or coma or
resulted in emergency room evaluation or hospitalization.
Has the individual
experienced any severe
hypoglycemic episodes
within the preceding 3
months?
Yes

No

If "Yes", Date of Occurrence
(mm-dd-yyyy)

If "Yes", has the cause been If, "Yes", provide details.
addressed?

Yes

No

HbA1C
Has the individual had
HbA1C measured
intermittently over the last
12 months including a
recent measurement within
the last 3 months?
Yes
DS-6575
03-2024

Provide a copy of the most recent result and enter the result here (including mm-dd-yyyy obtained).

No
Page 1 of 3

Name of Examinee

DOB

DIABETIC COMPLICATIONS
Renal disease/renal insufficiency (e.g., diabetic nephropathy, proteinuria)? Diabetic cardiovascular disease (e.g., coronary artery disease,
hypertension, stroke)?
Yes

No

Yes

Neurological disease/autonomic neuropathy (e.g., cardiovascular,
gastrointestinal)?
Yes

No

Peripheral neuropathy (e.g., sensory loss, loss of vibratory sense)?

No

Yes

No

Lower limb (e.g., foot ulcers, gangrene, infection)?
Yes

No

If any of the above
answers are yes:

Date of Dianosis (mm-dd-yyyy)

Current Treatment?

Stable Condition?
Yes

No

PROGRESSIVE EYE DISEASE(S)
Date of last comprehensive eye exam (mm-dd-yyyy)):?
Has the individual been diagnosed with either severe non-proliferative diabetic retinopathy or proliferative
diabetic retinopathy?
Yes

No

Has the individual been
diagnosed with any other
progressive eye disease(s)
(e.g., macular degeneration,
cataracts, glaucoma)?
Yes

If "Yes", Date of Diagnosis (mm-dd-yyyy)

If "Yes", Date of Diagnosis
(mm-dd-yyyy)

If, "Yes", Current Treatment

No

If "Yes", Stable Condition?

Yes

No

RESTRICTIONS
If, "Yes", provide details.
Are there any local (host
nation) restrictions related to
insulin treated diabetes (or
non-insulin treated diabetes)
and professional driving?
Yes

No

COMMENTS
Treating clinician should comment here on treatment plan if HBA1c is above 10, if recent hypoglycemic episodes, and/or if diabetic complications.

DS-6575

Page 2 of 3

Name of Examinee

DOB

Section III: Provider/Clinician Recommendation
IF LESS THAN 1 YEAR
______________ (initial): I attest that I am a treating
clinician and have treated the individual’s diabetes mellitus
for _____________ (# of years).

Please comment below on your knowledge of this individual’s diabetes
treatment plan.

Based on my assessment above, performed on ________________________ (mm-dd-yyyy):
The individual can safely drive, without restrictions.
The individual can safely drive with the following restrictions/limitations:
The individual should not drive at this time.
Name of Provider/Clinician

Signature of Provider/Clinician

Clinic Address/Post

Phone Number

Medical Credential/Specialty

Email

*Note: even if the documentation indicates the individual can drive, this document will be reviewed as part of the overall driver medical
evaluation and in accordance with the US Department of State Bureau of Medical Services Driver Medical Evaluation Policy.
Paperwork Reduction Act Statement
Releases or disclosures of confidential medical information are governed by the Privacy Act of 1974, as amended, 5 U.S.C. § 552a et seq., and the
Rehabilitation Act of 1973, as amended, 29 U.S.C. § 701 et seq.
Privacy Act Statement
AUTHORITIES: The information is sought pursuant to 5 CFR 930.108, 339.301 and the Foreign Service Act of 1980, as amended (Title 22 U.S.C.
4084, 3901, and 3984).
PURPOSE: The information requested on this form will be used to determine medical eligibility for issuance of a driver medical certificate.
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether
Federal, state, local, or foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order.
The information may also be made available to local Health Units. More information on the Routine Uses for the system can be found in the System of
Records Notice State-24, Medical Records
DISCLOSURE: Providing this information is voluntary; however, failure to provide this information may result in denial of a driver medical certification.
The Genetic Information Nondiscrimination Act of 2008 (GINA)
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008
(GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you NOT provide any genetic
information when responding to this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical
history, the results of an individual's or family members' genetic tests, the fact that an individual or an individual's family member sought or received
genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual
or family member receiving assistive reproductive services.
DS-6575

Page 3 of 3