Life Diabetes Referral 130308

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					                                                   REFERRAL FORM
Referral date: <<Miscellaneous:Date (long)>>           GP Review date: <<GP Review date>>
(Note: The patient must be 50 years or over or an adult Aboriginal or Torres Strait Islander person to be
eligible for the program.)
 Referral to:                                            Referring General Practitioner:
 Life! Taking Action on Diabetes                         <<Doctor:Full Details>>
 Diabetes Australia – Vic
 570 Elizabeth Street, Melbourne 3000
 Fax: 9667 1778

 Patient/Client details:
 <<Patient Demographics:Full Name>>                       Tel (H): <<Patient Demographics:Phone
 <<Patient Demographics:Full Address>>                    (Home)>> Tel(W): <<Patient
                                                          Demographics:Phone (Work)>>
 Preferred name: <<Patient                                Mobile: <<Patient Demographics:Phone
 Demographics:Greeting>>                                  (Mobile)>>
 Date of birth: <<Patient Demographics:DOB                eMail: <<Patient Demographics:E-mail>>
 (long)>>                                                 Medicare No: <<Patient Demographics:Medicare
 Sex: <<Patient Demographics:Sex>>                        Number>>
 Country of birth: <<Patient country of birth>>           DVA Number (if applicable): <<Patient
 Main language spoken at home: <<Main                     Demographics:DVA Number>>
 language spoken at home:>>                               Pension Number (if applicable): <<Patient
 Aboriginal: <<Aboriginal>>      Torres Strait            Demographics:Pension Number>>
 Islander: <<Torres Strait Islander>>

 Reason for patient referral: Prevention of diabetes
 Diabetes risk score: <<Diabetes risk score>>
 Diabetes excluded (in last 12 months): <<Diabetes excluded (in last 12 months)>>

Clinical Information:
 Warnings: <<Clinical Details:Warnings>>                 Allergies: <<Clinical Details:Allergies>>

Blood Pressure: (Delete unnecessary rows if necessary)
<<Clinical Details:Measurements>>

 Waist circumference:

Weight: (Delete unnecessary rows if necessary)
<<Clinical Details:Measurements>>

Height: (Delete unnecessary rows if necessary)
<<Clinical Details:Measurements>>

Current Medications:

Past Medical History:
CVD: <<CVD>>          Depression: <<Depression>>              Smoking: <<Clinical Details:Smoking>>

Investigation/Test results (within last 12 months):
Please select the following results within the last 12 months:
FBG (attach OGTT result if FBS >5.5, < 7.0);           LIPIDS: TC, HDL, LDL, TRIGs

<<Summary:Investigation Results (Selected)>>

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!

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
                                              Fax: 9667 1778
                                         Diabetes Australia ABN 47 008 529 461

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