Notification of New Diabetic Form V5 27092012 county by CRFe4IU

VIEWS: 0 PAGES: 2

									       Notification of New Diabetic Referral form
Please use this form for the following services –

                                                                         Diabetes
                                                                                 & You
                                                                          A group education programme for
                                                                             people with Type 2 Diabetes




Please copy and paste the following email addresses into your NHS mail address ‘To’ box
dhft.diabetic@nhs.net; dco-pct.DiabetesandYou@nhs.net

Please fill in the below table and either copy and paste the table into your email text box or send
this whole document as an email attachment once complete.
NHS Number
Title
Forename
Surname
Address


Town
County
Postcode
Home telephone number
Mobile telephone number
Date of Birth
Gender
GP
GP Address

Diabetes Type
Date Diagnosed as
Diabetic
Does this patient need to    Yes       No         If ‘No’ please give a reason i.e under the care of an
be invited for a screening                        ophthalmologist (please give as much detail as possible, including
                                                  hospital, consultant and date of last follow up), or medically/mentally
appointment?                                      unfit.




Main Language
Name of person making
referral

Diabetic Retinopathy screening – Dawn McAleer Tel: 01332 254977, Fax: 01332 783713


       For referral to a Diabetes & You programme continue overleaf
                        Diabetes & You Programme
For people newly diagnosed with Type 2 diabetes within the year or in need of basic education
for Type 2 diabetes.
Please note: not suitable for people on insulin or who have been diagnosed with Type 1
diabetes.

Please provide the following information to enable patients to plan and set goals for their
diabetes management whilst attending the course and for audit purposes.

Date Diagnosed with
Type 2 Diabetes
                           Yes             No
Requires invitation to
‘Diabetes and you’
                           Yes             No
Is patient aware of
referral? Please tick
                           Date            Result
HbA1c
                           Date            Result
Total Cholesterol
                           Date           Result
Blood Pressure

                           Date            Result
Body Mass Index
Waist circumference
(if known)

Smoking Status

Main Language

Name and contact no of
person making referral

Contacts-

Diabetes and You Education Programme – Stella Wiggin Tel: 01629 817995

								
To top