DESMOND Patient Data Collection Form
Form to be completed in full, please write clearly in BLOCK CAPITALS or typed
Patient Details
GP name: __________________________
NHS Number : __________________________
Name: Mr/Ms/Miss/Dr
________________________________________
Full Postal Address
________________________________________
Practice Address:
_______________________________________
_______________________________________
_______________________________________
_______________________________
________________________________________
Postcode:________________________________
Telephone No: ___________________________
Name of referrer: ______________________
Role of referrer: _______________________
Mobile No: ______________________________
Age: _________
Date of referral: ________________________
Date of Diagnosis __________ Male / Female
Ethnicity: _____________________________
Date of Birth: ____________
Biochemical Referral criteria - diagnostic
Symptomatic
Asymptomatic - tests repeated on 2
separate occasions (ideally within 2 weeks)
Repeated HbA1c (non-diagnostic)
Tick one (please state
level)
Fasting glucose >7
Random Glucose >11
HbA1C ≥ 48mmol/mol
OGTT >11.1mmol
Fasting glucose >7
Random Glucose >11
HbA1C ≥ 48mmol/mol
OGTT >11.1mmol
Date
Other Referral criteria
Tick to
confirm
Over 18
Aware of diagnosis and willing to participate in group education
Able to understand English
No drug or alcohol related problems that will prohibit participation in group education
Please include any factors we need to take into consideration e.g. wheelchair user,
able to lip read
Type 2 diabetes but have not attended structured education
Consider alternative methods of education if:
Type 1 diabetes – confirmed or suspected diagnosis
Too frail to attend and participate in an intensive full day of education
Deaf without the ability to lip read
Learning disability
Other serious co-morbidity or life limiting condition
Individual will benefit from 1:1 due to length of diabetes - Dietitian/ DSN (pls delete)
Please complete page 2.
Please complete the following information in FULL. This form will be used by trainers
and attendees during the session – please indicate if results are unavailable & reason.
Date measures taken:
Measure
Measure
HbA1c mmol/mol
BP (mmHg): Systolic
Total Cholesterol (mmol/l):
BP (mmHg): Diastolic
Fasting Y/ N
HDL (mmol/l):
Weight (kg): without shoes
LDL (mmol/l):
Height (cm): without shoes
Waist (cm):
Medication – please list or attach
Please return this completed form to your local DESMOND office:
Anne English
Clerical Assistant
Dietetic Department
George Eliot Hospital
College Street
Nuneaton
CV10 7DJ
Phone 02476865098
Fax 02476865089