Pre-Diabetes Worksheet

Item 48: Clinical Checklist for Pilots with Hyperglycemia

Apr 2014

Guidance is compiled and interpreted by professional pilots and physicians at FlightPhysical.com from the 2014 AME Guide page 114, FAA and FDA web data (www.FAA.gov & www.FDA.gov), instructions specified in the Aeronautical Information Manual, Federal Air Surgeon Bulletins from 1999-2015, and 14 CFR Part 61 and Part 67 (the FARs).


Includes: Metabolic Syndrome, Impaired Fasting Glucose, Insulin Resistance, Glucose Elevation/Intolerance, Polycystic Ovary Syndrome

The AME must review a current status report by the treating physician and any supporting documents to determine the applicant's eligibility for certification. If the applicant meets ALL the acceptable certification criteria listed below, the AME can issue. Applicants for first- or second- class must provide this information annually; applicants for third-class must provide the information with each required exam.

Metabolic Conditions Involving Poor Glucose Control

Pre-Diabetes Worksheet

AME MUST REVIEW

ACCEPTABLE CERTIFICATION CRITERIA

AME MUST REVIEW

ACCEPTABLE CERTIFICATION CRITERIA

Treating physician finds the condition stable on current regimen and no changes recommended

[ ] Yes

Symptoms associated with diabetes

[ ] None

Hypoglycemic events (symptoms or glucose less than or equal to 70 mg/dl) within the past 12 months.

[ ] None

Fasting blood sugar

[ ] Less than 126 mg/dl

Current A1C

[ ] Within last 90 days

[ ]Less than or equal to 6.5 mg/dL

Oral glucose tolerance test, if performed

[ ] Less than 200 mg/dl at 1 hour

[ ] N/A

Medications for condition

[ ] None

[ ] Metformin only (with no side effects)

AME MUST NOTE in Block 60 either of the following:

[ ] Airman meets certification criteria for pre-diabetes (Metabolic Syndrome, Impaired Fasting Glucose, Insulin Resistance, Glucose Elevation/Intolerance, Polycystic Ovary Syndrome).

[ ] Airman had previous Special Issuance for this condition and now meets the regular issuance certification criteria for pre-diabetes (Metabolic Syndrome, Impaired Fasting Glucose, Insulin Resistance, Glucose Elevation/Intolerance, Polycystic Ovary Syndrome).

[ ] Airman does NOT meet certification criteria for pre-diabetes (Metabolic Syndrome, Impaired Fasting Glucose, Insulin Resistance, Glucose Elevation/Intolerance, Polycystic Ovary Syndrome)). I have deferred this exam. (Mail the supporting documents to FAA identifying which criteria were not met.)


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