Referral Form for Xpert Diabetes and Xpert Insulin Structured
Diabetes Education Programmes
Please complete all details. Failure to do so may delay patients being seen.
XPERT DIABETES (This course is also a pre-requisite course for XPERT Insulin)
This session is for people who have been diagnosed with Type 2 diabetes in the last 3 months.
Patients attending this session do not need a separate referral for the dietitian.
THIS SESSION IS UNSUITABLE FOR:
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

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People with Type 1 diabetes
Patients already attending hospital for diabetes care
Patients who have been diagnosed longer than 6 months
Patients who are not suitable for group education (e.g. deaf, learning difficulties)
XPERT INSULIN
This session is suitable for all patients with Type 1 and Type 2 Diabetes (who are on Insulin)
Key messages covered:
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


Self management of diabetes and achieving HbA1C, BP and lipid targets
Lifestyle and diet advice
Diabetes treatments
Importance of attending annual review and eye screening
Patient’s Details
Name:
Address :
Post Code
Telephone Number :
Mobile Number:
Date of Birth:
NHS Number:
Ethnicity:
Does the patient need an interpreter?
Yes
No
GP Details:
Please specify language:
Name:
Address :
Post Code
Telephone Number :
Fax Number:
Referrer’s Details:
Name:
Date:
Please complete or attach the last recorded entries, this is required for
National X-PERT Database
Relevant History and Treatment
Date of Diagnosis:
Results
Height (cm)
Weight (Kg)
BMI (Kg/m2)
Waist circumference (cm)
HbA1c (mmol/mol)
BP (mm/Hg)
Total cholesterol (mmol/l)
HDL (mmol/l)
LDL (mmol/l)
Triglycerides (mmol/l)
ACR (mg/mmol)
eGFR (ml/min/1.73m²)
Depression score
Diabetes medication /dosage
Blood Pressure medication /dosage
Blood Lipids medication /dosage
Obesity medication /dosage
Other medication /dosage
Date
Please tick / highlight relevant course:
Venues for Xpert Diabetes
Day
Monday
Morning
Afternoon
 Balsall Heath Health
Centre
Tuesday

Soho Health Centre

Soho Health Centre `

Stockland Green Primary Care
Centre

Stockland Green
Primary Care
Centre

Washwood Heath Health &
Wellbeing Centre

Washwood Heath
Health & Wellbeing
Centre

Finch Road Health
Centre

Washwood Health
Centre
Wednesday

Partners in Health
Thursday

Sparkbrook Health Centre

Sutton Church
Day
Tuesday
Evening (18:00 – 20:30)
 Stockland Green Primary Care Centre
Venues for Xpert Insulin:
Day
Tuesday
Thursday
Morning
Finch Rd Primary Care Centre (Lozells)
Afternoon
Soho Health Centre
Please refer by: by email to [email protected] or by faxing to the relevant
locality teams:-
Fax the completed booking
form:
Fax number: 0121 682 7413
Post: Complete the booking form and send to:
X-Pert Programme,
Birmingham Community Nutrition
Birmingham Community Healthcare NHS Trust
2 Finch Road
Lozells
Birmingham
B19 1HS