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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.
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Pre-Diabetes Worksheet | |||
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AME MUST REVIEW |
ACCEPTABLE CERTIFICATION CRITERIA |
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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.)
Get PDF version of this same worksheet (2013)
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