Patient details
Referral Date: : Miscellaneous.Date Does your patient speak English? o Yes o No
Name Patient Demographics.Full Name What is the main language spoken at home? _____________
Address: Patient Demographics.Address Aboriginal or Torres Strait Islander descent: o Yes o No
Patient Demographics.Suburb Patient Demographics.Postcode Current smoker: <<Clinical Details:Smoking>>
Blood pressure: systolic systolic/ diastolic diastolic
Phone: Patient Demographics.Phone (Home) Waist circumference (cm): Waist circumference
Email: Patient Demographics.E-mail
DOB: Patient Demographics.DOB Gender: Patient Demographics.Gender
Country of birth: Country of Birth Cultural background: Cultural background
Past medical history
Clinical Details.Past History
Life! program exclusion criteria:Diabetes Pregnancy Active cancer Cardiovascular Disease (CVD) diagnosis in the last 3 months
It is important to consider the suitability of the Life! program for each individual.
Patient eligibility
See over for further information and definitions.
Choose one of the following A OR B OR C:
o A ------> OR o B ------> OR o C
≥ 18 years and AUSDRISK ≥ 12
and BMI ≥ 25 kg/m2 (if patient self-
identifies as being of Asian background
a BMI - 23kg//m2 is accepted)*
Height (cm): Height (cm)
Weight (kg): Weight (kg)
MBS items apply for a health assessment:
701, 703, 705, 707, 715
≥ 45 years (≥ 35 years if Aboriginal or Torres Strait Islander) and cardiovascular disease absolute risk score
≥ 10%
CVD risk score: CVD risk score
The following time-based
MBS item applies for a heart
health check: 699, 177
≥ 18 years with one or more of the following pre-existing conditions
(Please tick ü and document):
o Cardiovascular disease* o Chronic Kidney Disease
o Chronic Kidney Disease o Gestational diabetes
o Polycystic ovary syndrome o Familial hypercholesterolemia
o Serum total cholesterol > 7.5mmol/L (initial reading):
o Syst BP of ≥ 180 mmHg
or Diast BP ≥110mmHg (reading):
For further information or clarification, please refer to the definitions page.
Referrer details Completing the referral
Name: Treating Doctor.Name
Clinic: Practice.Name
Address: Treating Doctor.Address
Treating Doctor.Suburb Treating Doctor.Postcode
Phone: Treating Doctor.Phone
Fax: Treating Doctor.Fax
Email: Treating Doctor.E-mail
By signing this form, you agree that you have explained to your patient and, in your opinion, they understand that Diabetes Victoria collects their personal information for the purposes of Life! program registration, administration, participation, monitoring and evaluation.
ü Tick to confirm
o Blood pathology report within 12 months of referral date
o Fasting Blood Glucose (or HbA1C)
o Full Lipid Profile (TC/TRIG/HDL/LDL)
o Completed AUSDRISK form if using criteria A
o Diabetes excluded
o Patient consents to be enrolled in the program
o Patient consents to be contacted for research, marketing activities and other purposes
*For further information or clarification, please refer to the definitions page.
Return completed referral to:
Fax: 03 9667 1757
Mail: Diabetes Victoria
570 Elizabeth Street
Melbourne, VIC 3000
Phone: 03 8648 1880
Data Collection at Diabetes Victoria Diabetes Victoria is the leading charity and peak consumer body working to reduce the impact of diabetes. Data will be collected by Diabetes Victoria on all individuals referred to the Life! program. To maintain the confidentiality of your personal information, we comply with all Commonwealth and State privacy legislation. A copy of our Privacy Policy is available upon request. Your information will be used to assess the effectiveness of the Life! program. It will be stored in a secure database and only accessible by the organisation providing the Life! course and management of the Life! program.
Diabetes Victoria ABN 47 008 529 461
1. Your age group:
Under 35 years ¨ 0 points
35–44 years ¨ 2 points
45–54 years ¨ 4 points
55–64 years ¨ 6 points
65 years or over ¨ 8 points
2. Your gender:
Female ¨ 0 points Male ¨ 3 points
3. Your ethnicity/country of birth: Ethnicity
a. Are you of Aboriginal, Torres Strait Islander,
Pacific Islander or Maori descent?
No ¨ 0 points Yes ¨ 2 points
b. Where were you born?
Australia ¨ 0 points
Asia, Middle East, North Africa,
Southern Europe ¨ 2 points
Other ¨ 0 points
4. Have either of your parents, or any of your
brothers or sisters been diagnosed with diabetes
(type 1 or type 2)?
No ¨ 0 points Yes ¨ 3 points
5. Have you ever been found to have high blood
glucose (sugar) for example, in a health examina-
tion, during an illness, during pregnancy?
No ¨ 0 points Yes ¨ 6 points
6. Are you currently taking medication
for high blood pressure?
No ¨ 0 points Yes ¨ 2 points
7. Do you currently smoke cigarettes or any other
tobacco products on a daily basis?
No ¨ 0 points Yes ¨ 2 points
8. How often do you eat vegetables or fruit?
Everyday ¨ 0 points
Not everyday ¨ 1 points
9. On average, would you say you do at least 2.5
hours of physical activity per week (for example,
30 minutes a day on 5 or more days a week)?
Yes ¨ 0 points No ¨ 2 points
10. Your waist measurement taken below the ribs
(usually at the level of the navel, while standing):
Waist measurement (cm) _________________
Complete either the green or orange box below,
as appropriate.
For those of Asian or Aboriginal or Torres Strait
Islander descent:
Men Men
Less than 90cm Less than 80cm o 0 points
90–100cm 80–90cm o 4 points
More than 100cm More than 90cm o 7 points
For all others:
Men Women
Less than 102cm Less than 88cm o 0 points
102–110cm 88–100cm o 4 points
More than 110cm More than 100cm o 7 points
Add up your points
Your risk of developing type 2 diabetes within 5 years*.
5 or less: Low risk
Approximately one person in every 100 will
develop diabetes.
6-11: Intermediate risk
For scores of 6–8, approximately one person
in every 50 will develop diabetes. For scores of
9–11, approximately one person in every 30
will develop diabetes.
12 or more: High risk
For scores of 12–15, approximately one person
in every 14 will develop diabetes. For scores
of 16–19, approximately one person in every
seven will develop diabetes. For scores of 20 and
above, approximately one person in every three
will develop diabetes.
* The overall score may overestimate the risk of
diabetes in people younger than 25.
The Australian Type 2 Diabetes Risk Assessment Tool was originally developed by the
International Diabetes Institute on behalf of the Australian, State and Territory Governments
as part of the COAG Diabetes reducing the risk of type 2 diabetes initiative.
A AUSDRISK + BMI C Pre-existing conditions
The Australian type 2 diabetes risk assessment tool (AUSDRISK) is a short list of questions to help assess a person’s risk of developing type 2 diabetes over the next five years.
Body mass index (BMI) is one way to assess whether a person’s weight is in the healthy range. The BMI combines a person’s height and weight to form a measure that can help predict their risk of developing disease.
weight kg)
Body mass index = --------------
height (m)2
The following time-based MBS items apply for a
health assessment: 701, 703, 705, 707, 715
Asian sub-regions
Asian background includes three distinct sub- regions (Parliament of Australia, 1997):
Northeast Asia (Mainland China, Hong Kong, Japan, Korea, Taiwan);
Southeast Asia (Brunei, Cambodia, Indonesia, Laos, Malaysia, Burma (Myanmar), the Philippines, Singapore, Thailand, Vietnam); and
Southern Asia (Afghanistan, Bangladesh, India, Pakistan, Sri Lanka, Nepal).
Cardiovascular disease*1
• Acute rheumatic fever/rheumatic heart disease
• Angina
• Angioplasty
• Arrhythmias/Atrial fibrillation
• Cardiomyopathy
• Chronic Heart Failure
• Coronary Heart Disease
• Myocardial infarction
• Peripheral Vascular Disease
• Stroke
*Must not have been diagnosed within the last 3 months
*Must be medically stable and must not have had a hospital admission in the last 12 months for the condition
Gestational diabetes
To participate in the program, women must not be pregnant.
Moderate or severe kidney disease2
• Persistent proteinuria or GFR < 45mL/ min/1.73m2 or
• stage 3b chronic kidney disease or greater
Impaired glucose tolerance (IGT)
Blood glucose level is higher than normal two hours after a glucose load is taken orally, but not high enough to be diagnosed as diabetes. Two-hour plasma glucose is between 7.8 and 11.0 mmol/L.
Fasting blood glucose level may still be in the normal range.
Familial hypercholesterolemia7
The Dutch Lipid Clinic Network Score Criteria required for diagnosis.
Serum cholesterol >7.5 mmol/L
If on medication managing the condition,
patient is still eligible for the program.
Systolic BP ≥ 180mmHg or diastolic
BP ≥ 110mmHg8
If on medication managing the condition,
patient is still eligible for the program.
Polycystic Ovarian Syndrome9
Rotterdam diagnostic criteria. Requires two of:
• Oligo- or anovulation
• Clinical and/or biochemical hyperandrogenism
• Polycystic ovaries on ultrasound (and exclusion of other aetiologies)
Pre-diabetes3 4 5 6
Blood glucose levels are higher than
B Cardiovascular risk score normal but not high enough to be
The Australian Absolute risk calculator combines several risk factors to calculate a risk score (expressed as a percentage), which is a person’s chance of having a CVD event such as a heart attack or stroke in the next five years.
classified as diabetes.
There are two pre-diabetes conditions:
Impaired fasting glucose (IFG)
Blood glucose levels are escalated in the fasting state but not high enough to be classified as diabetes. It is diagnosed on the basis of a result between 6.1 and 6.9 mmol/L
Blood Test Results6 Diagnostic criteria for type 2 diabetes
(RACGP clinical guidelines 2016-2018)10
A patient’s blood test result is required to ensure that type 2 diabetes has been excluded. Please attach patient blood test results within the last 12 months of the Life! referral date.
• Full Blood Lipids
• Fasting Blood Glucose (FBG) or HbA1c
Further testing to exclude type 2 diabetes
• If FBG is 5.5 - 6.9 mmol/L an Oral Glucose Tolerance
Test (OGTT) is recommended.
These are via venous sampling under laboratory methodology.
Patient is excluded from the program if they meet one or more of the following:
• Fasting blood glucose (FBG) ≥7.0 mmol/L or random blood glucose
≥11.1 mmol/L confirmed by a second abnormal FBG on a separate day
• Oral glucose tolerance test (OGTT) before (fasting) and two hours after
an oral 75 g glucose load is taken. Blood glucose is measured. Diabetes is
diagnosed as FBG ≥7.0 mmol/L or two-hour blood glucose is ≥11.1 mmol/L
• Glycated haemoglobin (HbA1c) ≥48 mmol/mol (6.5%; on two
separate occasions)
These are via venous sampling under laboratory methodology.
1 Heart Foundation
2 Kidney Health
3 Diabetes Australia
4 National Diabetes Services Scheme
5 Royal Australian College of General Practitioners LTD (RACGP)
7 Familial Hypercholesterolemia Australasia Network
8 Heart Foundation
9 Jean Hailes for Women’s Health