REFERRAL FORM

Referral Date: Miscellaneous.Date GP Review Date:

Note: Patient must be 50 years or over, or an adult Aboriginal or Torres Strait Islander to be eligible for the program.

Reason for patient referral: Prevention of diabetes

Referral to: Name: Addressee.Name Address: Addressee.Full Address Phone: Addressee.Phone Fax: Addressee.Fax Email: Addressee.E-mail		Referring General Practitioner (stamp): Treating Doctor.Name Treating Doctor.Full Address
Patient / Client details:
Title Patient Demographics.Title Name: Patient Demographics.First Name Patient Demographics.Surname Preferred name/s: Patient Demographics.Popular Name . Date of Birth: Patient Demographics.DOB Sex : Patient Demographics.Gender		Address: Patient Demographics.Full Address . Phone: H: Patient Demographics.Phone (Home) W: Patient Demographics.Phone (Work) Mobile: Patient Demographics.Phone (Mobile) Email: Patient Demographics.E-mail
Pension Card Number: Patient Demographics.Pension Number Medicare/DVA Number: Patient Demographics.Medicare Number Patient Demographics.DVA Number Country of Birth: Main language spoken at home: Are you of Aboriginal or Torres Strait Islander origin? Yes No (Aboriginal) Yes No (Torres Strait Islander)

Diabetes Risk Score:

Diabetes excluded (in last 12 months) Yes No (please attach FBG or OGTT result if FB >5.5, < 7.0)

_______________________________________________________________________________________________________________________________________________________________________________________

Clinical Information:

Warnings:

Allergies: Clinical Details.Allergies

BP: Waist circumference: cms Weight: Kgs Height: cms

(To one decimal point)

Current Medication:

Clinical Details.Medication List

Past Medical History:

CVD: Yes No Depression Yes No Current smoker: Clinical Details.Smoking

Others:

Investigation / Test Results (within last 12 months):

Please attach the following results taken within the last 12 months:

FBG (attach OGTT result if FBS >5.5, < 7.0); LIPIDS: TC, HDL, LDL, TRIGs

Patient information:

Data collection at Diabetes Australia Vic

Diabetes Australia Vic is the peak consumer body and leading charity representing all people affected by diabetes and those at risk.

Data will be collected by Diabetes Australia - Vic on all participants who attend the Life! - Taking Action on Diabetes 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 organization providing the Life! course and management of the Life! Program.

Research Opportunities

From time to time, opportunities will arise for people at risk of diabetes to participate in research activities.

Please tick here if you DO NOT want to participate in research or receive information about further research into the prevention of diabetes.

If you have any questions regarding the completion of this form call 1300 136 588. Please send the completed form to:

Life! Taking Action on Diabetes

Diabetes Australia Vic

570 Elizabeth Street, Melbourne 3000

or

Fax: 9667 1778

Diabetes Australia ABN 47 008 529 461